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Exercise Adherence; The Battle Continues

This post has taken a little time to put together with a house move and Christmas in the middle. I hope you enjoy reading it and can take something from it that you may find helpful with your own patients. It certainly has refreshed and changed my practice when it comes to exercise prescription.

Within this second post, there is exploration of interventions to improve adherence to a HEP for patients with LBP and how they link to behaviour change.

Systematic Reviews, Interventions to Aid Adherence

I have identified four systematic reviews (Peek et al. 2016, Jordan et al. 2010, McClean et al. 2010 and Beinhart et al. 2013) that focus on interventions to aid patient adherence to physiotherapy and give a good overview of key factors (Table 3 has a summary of these). Beinhart et al. (2013) is the only review specific to LBP.

From these reviews, the common interventions that may improve adherence are; provision of supporting materials such as an exercise sheet or video, regular follow up and supervision, attendance on exercise programmes, education, establishment of rapport, social support, goal setting, behavioural contracts, individualised programmes and use of cognitive behavioural strategies. There is no evidence to suggest one form of exercise is better than another at improving adherence and it appears, from current research, that improving long term adherence is difficult.

There were common limitations with all papers. The lack of similarity between research used within the reviews, led to all reviews using a narrative summary to describe their results rather than using meta-analysis.  As mentioned in my previous post, all authors noted that there is a lack of a validated outcome measure to measure home exercise adherence,  making it difficult to draw conclusions from current research. Additionally, Beinhart et al. (2013) noted that, at times, it is difficult to understand the intervention carried out within research, suggesting that therapists should consider using The Behaviour Change Taxonomy (Michie et al. 2013) to allow better identification of interventions, which would then allow replication in clinical practice. Cognitive behavioural strategies possibly have improved short term adherence but had no long term effect (McClean et al 2010 and Peek et al. 2016). Both McClean et al (2010) and Peek et al. (2016) suggest that delivering these interventions could be considered a specialist skill and question the therapist’s ability to deliver effective intervention. They urge readers to consider this as a limitation of research so far.

There is consensus that it is difficult to recommend one form of intervention over another due to lack of data and a small number of studies, many of which do not use adherence as their primary outcome measure (Peek et al. 2016, Jordan et al. 2010 and Beinhart et al. 2013). There is a suggestion that, as a therapist, having an awareness of possible barriers and the ability to utilise a broad range of interventions may be the optimal approach (McClean et al. 2010).

Table 3. Summary of Systematic Reviews Focused on Adherence

Title of Systematic Review	Overview	Analysis	Interventions noted to improve adherence	Main Conclusions
Peek et al. (2016) Interventions to aid patient adherence to physiotherapist prescribed self-management strategies.	·      12 Studies included. ·      Explored exercise as self- management but not exclusive to the musculoskeletal population. ·      All RCT’s.	Narrative summary	·         Education ·         Written Information ·         Activity Monitor ·         Effective Communication ·         Patient-therapist rapport ·         Social Support and encouragement ·         Goal setting ·         Behavioural exercise programme ·         If treatment is initially more effective prompts better adherence ·         Individual tailored	Suggest that insufficient research to endorse one type of behaviour change technique or intervention over another.     Noted lack of research in this area and no validated measure of adherence.
Jordan et al. (2010) Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults.	42 trials, 17 of which included spinal pain. All RCTs.	Narrative Summary	·         Supervised exercise and regular follow-up to reinforce self-management strategies. ·         Educational strategies such as goal setting and behaviour contracts may be useful. ·         Supplementary materials – exercise sheets etc. ·         Programmes which prepare individuals for self-management ·         Cognitive Behavioural Techniques	Also noted very difficult to draw firm conclusions.   Noted a lack of validated outcome measure, lack of research looking at long term adherence and lack of research using adherence as a primary outcome measure.
McClean et al.(2010) Interventions for enhancing adherence with physiotherapy	·         5 studies ·         Very small and not just exercise. ·         All RCT’s.	Narrative Summary	·         Limited evidence for supplementary materials such as exercise sheets and video. ·         Some evidence to suggest cognitive behavioural interventions may increase short term adherence but not long term.	Difficult to draw conclusions due to lack of research in MSK setting.   Identify poor outcome measures for adherence is problematic.   Note that cognitive behavioural intervention may not be effectively delivered by untrained therapists, this maybe influencing outcome of research.   Suggest therapists should be aware of barriers and interventions and utilise what is appropriate with an individual.
Beinhart et al. (2013) Individual and intervention-related factors associated with adherence to home exercise in chronic low back pain	11 RCTs and 3 non-RCTs.   Note: This is the only systematic review specific to exercise adherence in a population with LBP.	Narrative Summary	·         Higher health locus of control. ·         Increased Supervision ·         Additional participation in an exercise programme. ·         Participation in Behaviour Change Programme.	Difficult to draw firm conclusions as they report often it is not clear what intervention has been carried out and poor outcome measures.   Suggestion that in the studies examined difficult to maintain true control as physiotherapy itself often aims to facilitate behaviour change.

Some interventions identified by Beinhart et al. (2013) have clear links to psychology, such as a behavioural change programme, which includes motivational interviewing and a back school incorporating psychology and education. Additionally, physiotherapists already use behavioural change techniques and may not have an awareness of this (Beinhart et al 2013). The most commonly utilised techniques are, “instruction on how to perform behaviour, demonstration of behaviour, behavioural practice, credible source, body changes, graded tasks, goal setting, action planning, coping strategies and self-monitoring”, (Keogh et al. 2015). Bassett (2015), in agreement with Keogh et al. (2015), suggests that, “verbal feedback, exercise testing, decision balance sheets, self-regulation, relapse prevention, progressed graded activities, booster sessions and action/coping plans”, are successful behaviour change techniques.

Behaviour Change

Hay Smith et al. (2016) and Bassett (2015) suggest exercise adherence can be enhanced through the understanding of health behaviour theory, understanding the individual patient and then using appropriate behaviour change techniques. I therefore endeavoured to develop my understanding of health behaviour theory.

Initially, I found the field of behaviour change and models of health behaviour confusing. A recent systematic review identified 82 different theories of health related behaviour (Davis et al. 2014). I have come across a number of models through my reading; the health belief model, the transtheoretical model, the theory of planned behaviour, the health action process approach and self-efficacy.  As a novice in this area, the complexity was daunting. During discussions with the wider physiotherapy community I was directed to the work of Michie and colleagues.

Michie et al. (2011) have developed a new model of health behaviour the COM-B Model (Figure 1).

Figure 1. COM-B Model – adapted from Michie et al. (2011)

Michie et al. (2011) explain that capability refers to a person’s physical and psychological ability to engage in change (which includes knowledge and skills), motivation refers to both conscious decision making and automatic processes (such as habit and emotion) and opportunity refers to factors that are not related to the person but make behaviour possible. For example, in the case of a patient with LBP who is struggling to complete home exercises, the model may look like that in Table 4:

Table 4 COM-B Model – Patient with LBP

Targeted Behaviour	Completing Home Exercises for LBP
Capability	Patient reports struggling to remember all the exercises they have been given.
Opportunity	Patient works full time, difficulty finding time to complete exercise. Lack of space at home to complete exercises.
Motivation	Keen to complete exercises as would like to resolve back pain to return to gardening

 

This is a simple starting point and, I believe, useful for a novice. It is considered an overarching model of health behaviour and, if required, an exploration of more specific psychological theory could follow (Barker et al., 2015). Michie et al. (2011) explain the COM-B Model of health behaviour sits at the middle of the Behaviour Change Wheel which, as a whole, is a framework to guide interventions (Atkins, 2015) (see Figure 2).

 

Figure 2. The Behaviour Change Wheel – Michie et al. (2011)

 

 

Figure 3. Further explanation of Intervention Function – Atkins (2015)

 

The second layer of the wheel highlighted in red refers to intervention functions (figure 3 gives further clarity of what is meant by intervention functions). Consideration of the most appropriate intervention function may then direct choice of behaviour change technique. For example, if applied to our LBP Patient, the process of understanding behaviour and selecting behaviour change technique may look like the process demonstrated in Table 5.

 

Table 5. Understanding behaviour and selecting the most appropriate behaviour change technique.

COM –B Model	Intervention Function	Possible Behaviour Change Technique	Practical Support
Capability – Patient reports struggling to remember all the exercises they have been given.	Modelling Enablement	Demonstration Of Behaviour (Exercises) Behavioural (Exercise) Practice Feedback on behaviour Biofeedback on Behaviour	Exercise sheets/videos
Opportunity – Patient works full time, difficulty finding time to complete exercise. Lack of space at home to complete exercises.	Education Persuasion Coercion Enablement	Goals Setting – Behaviour Verbal persuasion about ability Use of Prompts /Cues – for example complete exercises when having a cup of tea. Biofeedback on Behaviour
Motivation – Keen to complete exercises as would like to resolve back pain to return to gardening.	Persuasion	Goal setting – Outcome Action Planning Graded Exercise

 

I have included a final column on the right called Practical Support, which suggests interventions mentioned in the systematic reviews that could also support behaviour change.

There is a further layer of the behaviour change wheel pertaining to policy but I do not feel it relevant in the context of changing individual behaviour change to exercises.

As noted previously, physiotherapists already utilise a number of behaviour change techniques. Michie et al. (2013) have formed a taxonomy of 93 behaviour change techniques to enable interventions to be clearly defined and identifiable for both research and clinical practice. This is also accessible via a free app for iPhone or Android. Please refer to Table 6, which identifies the subheadings of techniques and to the paper or app noted above for a more detailed explanation of each technique.

Table 6. Behaviour Change Techniques

Sub Categories of Behaviour Change Techniques (Michie et al. 2013)
1.       Goals and Planning 2.       Feedback and Monitoring 3.       Social Support 4.       Shaping Knowledge 5.       Natural Consequences 6.       Comparison of Behaviour 7.       Associations 8.       Repetition and Substitution	9.       Comparison of Outcomes 10.   Reward and Threat 11.   Regulation 12.   Antecedents 13.   Identity 14.   Scheduled consequences 15.   Self-Belief 16.   Covert Learning

 

Different authors have different opinions on models of behaviour change. For example, Jordan et al (2010) suggest that no one single model or theory can be applied to gain a full understanding of adherence. I am in agreement with this and clinically I feel that combining the ideas of Michie et al (2011) and the practical applications noted by Bassett (2015) provides a simple and relatively quick framework to explore patients’ adherence to home exercises.

Bassett (2015) explains that, initially, patients should be asked to list as many barriers and facilitators to exercises as possible in a minute, followed by a brief discussion about methods they already use to maintain routine or attend appointments. This directs choice of behaviour change technique for an individual. As a therapist, combining this with the COM-B Model and The Taxonomy of Behaviour Change Techniques should ensure that a basic understanding of a patient’s behaviour has been grasped and ultimately leads to an individualised programme which facilitates a more successful treatment.

 Application to Clinical Practice

Barriers to exercises are varied, this will be different for each individual, but perceived lack of time appears to be a common theme. As a therapist, spending time identifying these with your patient may be invaluable. Secondly, although there are a number of systematic reviews, the limitations in the research mean that there are no firm answers as to the best method to increase adherence. However, a good knowledge of various interventions, knowledge of your patients’ behaviour and tailoring individual treatments may help improve adherence.

My personal thoughts are that if you are lacking in time to increase your understanding, try some quick-to-implement strategies: Such as the 1 minute identification of possible difficulties and facilitators with exercise and try to give no more than two exercises per session. I have produced a clinical practice flow diagram as a step by step guide to putting some points into practice in Figure 4.

Why have I written about this subject?

As a method of reflection on my own approach, I often use Bortons Developmental Framework because it is simple, asking three questions: What? So what? And What Now? (Rosser, 2013).

What? I, like many physiotherapists I know, use exercise with almost every patient. I was also aware that it was highly likely that my patients often do not complete their exercises.

So, what?

I began to think about the value of my role if I was unable to support a patient to complete exercise as it was likely I was having limited effectiveness.  These thoughts left me feeling frustrated and led me to try to understand the reasons why patients struggle to exercise and how this could be improved.

What, now?

During the process of investigation, my practice has changed; I am more open in discussing with patients that they may struggle to complete exercises, my approach has become more collaborative. A patient returned to me saying, “because you only gave me two exercises I was able to focus on them I have been completing them regularly and feel much better”.

I feel less frustrated as I now have strategies to help patients complete exercises. I am aware that behaviour change is complex and if I am able to continue my knowledge development in this area I believe it will have a positive effect on my practice in terms of therapeutic exercise and understanding limits to physical activity.

Figure 4. Clinical Practice Flow Diagram

 

References

Atkins, L. (2015) ‘Using the Behaviour Change Wheel in infection prevention and control practice’, Journal of Infection Prevention, 17(2), pp. 74-78

Barker, F., Mackenzie, E. and De Lusignan, S.(2016) ‘Current process in hearing-aid fitting appointments: An analysis of audiologists’ use of behaviour change techniques using the behaviour change technique taxonomy (v1)’, International journal of audiology, vol. 55, no. 11, pp. 643.

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.

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.

Davis, R., Campbell, R., Hildon, Z., Hobbs, L. and Michie, S. (2014) ‘Theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review’, Health Psychol, 8, pp1-22.

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.

Jordan, J.L., Holden, M.A., Mason, E.E. and Foster, N.E. (2010)’ Interventions to imporve adherence to exercise for chronic musculoskeletal pain in adults’. The Cochrane database of systematic reviews, 1.

Keogh, A., Tully M.A., Matthews, J. and Hurley, D.A. (2015) ‘A review of behaviour change theories and techniques used in group based self-management programmes for chronic low back pain and arthritis’, Manual Therapy, 20(6), pp. 727-735.

McClean, S.M., Burton, M., Bradley, L. and Littlewood, C. (2010) ‘Interventions for enhancing adherence with physiotherapy: A systematic review’, Manual Therapy, 15, pp 514-521.

Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., Eccles, M.P., Cane, J. and Wood, C.E. (2013) ‘The Behavior Change Technique Taxonomy (v1) of 93 Hierarchically Clustered Techniques: Building an International Consensus for the Reporting of Behavior Change Interventions’, Annals of Behavioral Medicine, 46(1), pp. 81-95.

Michie, S., Van Stralen, M.M. and West, R. (2011)’The behaviour change wheel: a new method for characterising and designing behaviour change interventions’, Implementation science, 6 (1), pp. 42-42.

Peek, K., Sanson –Fisher, R., Mackenxie, L. and Carey, M. (2016) ‘Intervention to aid patient adherence to physiotherapist prescribed self management strategies: a systematic review’, Manual Therapy, 102, pp.127-135.

Rosser, M., Mooney, G.P. & Jasper, M. (2013), Professional development, reflection and decision-making in nursing and healthcare, Second Edn, Wiley-Blackwell, Chichester.