Adherence to Home Exercise Programs

Original Editor - Laura Ritchie, posting on behalf of Yulia Biggar, MPT Class of 2016 at Western University, project for PT9585 Top Contributors - Laura Ritchie, Lucinda hampton, Kim Jackson, Tony Lowe, Candace Goh, Evan Thomas, WikiSysop and Claire Knott

Introduction

Adherence to home exercise programs (HEPs) in rehabilitation poses a significant challenge. The reasons for this issue are multifaceted, encompassing both psychological and situational factors that vary among individuals. Clinicians must consider these factors when designing personalised exercise programs.

• Delivering a home exercise program (HEP) to patients stands as one of the most fundamental and crucial aspects of physiotherapy .
• Patients who adhere to their prescribed exercises are significantly better at achieving their goals and demonstrate a greater increase in physical function.
• Patients adhere poorly to their prescribed home program, with varying estimations from research. Non-adherence to a home exercise program has been shown to be as high as 50-65% for general MSK conditions. In the low back pain patient population, non-adherence to home exercise has been shown to be as high as 50-70% .
• Non-adherence of a HEP increases the risk of recurrent injury or flare-ups with less positive outcomes long term and can result in the physiotherapist believing that their current treatment is not effective.
• Overall, there is a need for good quality evidence to identify potential barriers to patient adherence and the strategies that are effective at combating those barriers.

Factors Affecting Compliance and Performance

When setting a HEP remember that the long list you may put together may be all inclusive but research shows

• Subjects who were prescribed 2 exercises performed better than subjects who were prescribed 8 exercises, another report finding those prescribed 4 or more exercises had a lower rate of compliance than those prescribed 2 or fewer
• Subjects who are prescribed 2 exercises will perform better than subjects who are prescribed 8 exercises
• Subjects who are prescribed 2 exercises will comply on their self-report exercise log more than subjects who are prescribed 8 exercises
• Compliance with behavioural treatments (eg, an exercise program) is similar to drug compliance; as complexity increases, compliance decreases.

Factors Affecting Adherence

• Perceived Barriers - eg forgetting to exercise, not having the time, not fitting into the daily routine, work schedules(See image, busy multi tasking at home).

• Self-Efficacy ie an individual’s belief in their own capability to achieve a task that will produce a targeted result.
• Threat and Beliefs ie The beliefs a patient holds regarding their condition and the decisions made by patients are based on their own beliefs, personal experiences, and the information they receive.
• Locus of Control - patients with an external locus of control demonstrate a lesser degree of adherence with HEP.
• Pain - Pain levels during exercise in musculoskeletal patients presented strong evidence as a barrier to adherence in a systematic review.
• Physical Activity - Studies suggest that those who are physically active at baseline demonstrate significantly better adherence to HEPs.
• Psychological Symptoms - Depression as a barrier to adherence has strong supporting evidence.
• Social Support - The social support network of the patient has also been suggested as a possible factor in adherence eg friends and family members, as well as support from the therapist.

This is a good video (10 minutes) on barriers to exercise, or perceived barriers, to exercise and ways to overcome them.

Health Technologies

Health technologies, such as the use of mobile devices, including mobile phones and tablets, as well as software apps, provide us with the opportunity to better support the patient and clinician, with a data-driven approach that incorporates features designed to increase adherence to exercise such as coaching, self-monitoring and education, as well as remotely monitor adherence rates more objectively.

Software apps exist on the market and may well change the way of many home exercise plans in clinics. The promise to do such things as " make it easy to build a home exercise program in seconds, with beautifully designed instructional videos. The built-in efficiencies will reduce your workload. Plus, our software motivates your patients and improves outcomes, with tracking tools and insightful analytics." Research is yet to confirm this but many clients like the idea of visualisation and direct feedback

Combining the popularity of mobile devices with the on-going search for fitness, thousands of fitness applications (apps) are available for free or low cost. Apps allow users to set fitness goals, track activity, gather workout ideas, and share progress on social media. Physiotherapists should stay abreast with recent research and follow the guideline as they emerge.

• Those who utilised the apps were more likely to have a positive attitude about the apps.
• Usefulness and perceived difficulties in particular should be considered with future app development.
• App usefulness and ease of use may be facilitated by using health behaviour theories to guide development.
• One systematic review identified strong evidence for computerised technology not being more effective at improving HEP adherence compared to other strategies.

Strategies to Increase Adherence

Patient Education

• Educating patients on pain versus harm by explaining the nature of pain and nociception and suspending the belief that pain is an indicator of further tissue damage
• Reinforcing messages which reduce fear or anxiety about pain
• Emphasising the idea that exercise will lead to less pain, anxiety, and depression
• Countering maladaptive coping strategies
• Employing motivational techniques and Motivational interviewing to set personal treatment goals
• Managing expectations by educating patients the importance of their own HEP.

Treatment

• Minimising pain during a HEP eg heat, ice or TENS pre or post session.
• Use a graduated HEP - to reduce anxiety and fear avoidance, progress slowly and gradually to increase patients’ confidence in their own physical abilities
• Providing clear HEP, both printed and verbal instructions, when introducing a new exercise program, check patient's ability to recall.
• Encouraging patients to keep exercise logs, diaries, logs to track their progress, symptoms, etc
• Reviewing exercise and symptom logs at every treatment

Personalised Approach

• Tailoring exercise program demands to the patient. Patients should be introduced to regular exercise in small steps that they feel confident they can manage
• Participating in Telerehabilitation and Smartphone Apps in Physiotherapy in the form of email support or telephone support
• Providing patients with pictures and videos of themselves performing the prescribed exercises
• Establishing a personalised HEP negotiated and agreed upon with the patient
• Include social network, for encouragement and involvement, and to boost their confidence

These videos below (total 6 minutes) give insight to HEP and adherence.

Measurements of Adherence

• Diaries. Limitations - poor completion rates, inaccurate recall and self-presentation bias.
• Computer programs, phone applications and wearable technology (e.g. pedometers)
• See also Physical Activity and Outcome Measure

The following are samples of tools available to estimate patient adherence

1. Sports Injury Rehabilitation Adherence Scale (SIRAS)- 3-item scale completed by the therapist
2. Hopkins Rehabilitation Engagement Rating Scale (HREPS)- 5-item questionnaire completed by the health professional in an acute inpatient setting.
3. Adherence to Exercise Scale for Older Patients (AESOP)- patient completed 43-item questionnaire
4. The Modified Rehabilitation Adherence Questionnaire (RAQ-M)- 25-item scale to evaluate potential barriers to patient adherence

Barriers to Adherence

Level of Evidence

1. Strong

• Pain - worsening pain during a treatment session is associated with a barrier to a HEP .
• Low levels of physical activity at baseline - patients who are not used to following a regular fitness program are less likely to incorporate a physiotherapy exercise program into their schedule
• Low self-efficacy
• Anxiety or stress at baseline - strong predictor of poorer outcomes at long term follow-ups
• Depression - lower levels of depression are correlated to a greater motivation to exercising
• High degree of helplessness
• Lack of social support - the absence of a strong support network can lead to lower levels of adherence to a HEP
• Perceiving barriers to exercise eg transportation problems, child care needs, work schedules, lack of time, family dependents, financial constraints, convenience and forgetting
• High levels of neuroticism

2. Moderate

• Internal locus of control the belief that individuals are responsible for their own outcomes (adhere better to home exercise programs)

3. Limited Level of Evidence

• Higher disability level - those with higher disability level were more likely to adhere to a HEP
• Lower motivation - research shows no clear relationship between motivation level and adherence to HEP

4. Conflicting Evidence

• Greater pain at baseline - unclear whether greater pain at baseline serves as a motivating factor or a barrier to exercise adherence
• Age - currently there is evidence on whether older patients vs younger clients adhere more or less to their HEP
• Low levels of optimism - although low levels of optimism are associated with withdrawal from goal pursuits there is no clear evidence that it results in decreased adherence

Resources

This article by Bollen et al (2014) cites 58 studies reporting on 61 measures of self-reported adherence, thus the measures can be determined through using the reference list.