The eternal struggle for outcomes in physiotherapy is in large part due to compliance, or lack thereof. I’m going to break this concept down and attempt to arrive at some strategies. Non-compliance for exercise in physiotherapy has reported to be as high as 70% (Ref). Personally, I always knew compliance rates in physiotherapy were low, but to think it could be as low as 30% for any HEP is quite sobering. Of course, it is not so cut and dry as there are many nuances and intricacies in the massive issue of treatment adherence and by no means is physiotherapy alone in low compliance rates. But I would like to hazard a guess, that if not ‘sold’ well, compliance rates can be much higher than 70%.
So why so low?
A systematic review by Jack et al in 2010 (Ref) outlined factors affecting barriers to treatment adherence in physiotherapy outpatient clinics, these will seem obvious to the clinician, but appropriately researched (all cohorts, however):
–High levels of pain: I think physios are already pretty damn good at understanding patient’s experiences and beliefs about pain. It is one of the central tenants of our profession to challenge mal-adaptive responses to pain, so in this barrier, physiotherapists are already doing enough.
– Low levels of physical activity (PA): Again, this would seem like common-sense to the tuned in practitioner but in particular some interesting issues include poor programme organisation and leadership and poor education. Issues like poor history of exercise, perceived physical frailty, perceived poor health and readiness to change are other barriers to change, which make a fair bit of sense.
– Self-efficacy: If your patients have low confidence in your ability to undertake the exercises prescribed they will hardly go out of their way to actually do them. Again, this is something I think is done quite poorly; explained in the clinic on paper but never actually demonstrated and confronting patient’s low self-efficacy levels.
– Depression, anxiety & helplessness: Something that impacts on the entire picture of treatment of someone coming to the clinic, and something that should be at the forefront of ‘tackling’ as soon as possible.
– Low levels of social activity
– Patient’s perception of barriers to exercise: Now I think this can entail everything like, oh, say, the entirety of life, so in reality this is HUGE! So every time you hear, ‘I couldn’t do my exercises because I couldn’t find 5 minutes between walking from my desk at work to the printer,’ this is a perception thing, even though you have sold the ‘exercise thing’ phenomenally and removed seemingly every single barrier possible. I think this relates to the (transtheoretical) stage of change they are currently in and there are there are obviously other nuances here that complicate these perceptions (like depression, anxiety and helplessness above). There is evidence that implementing coping plans may help patients to overcome difficulties (Ref), but there are other strategies that may be of benefit that I will outline below.
In a newer systematic review, Beinart et al 2013 (Ref) (11 RCTs and 3 cohorts), outlined that distress levels, whether higher or lower were not overly associated with adherence in chronic low back pain patients. Higher pain levels were very weakly associated with lower adherence and the same can be said for disability levels.
So what can be done?
1. Communication is key.
Lonsdale et al 2017 (Ref) performed a large (n=308) well-designed RCT across multiple centres in Ireland. 50 physios delivered either a control intervention consisting of standard care for chronic low back pain patients or the treatment intervention, which consisted of motivational interviewing techniques designed to upgrade adherence. More on these techniques can be found here. When physiotherapists were trained in communication to increase adherence in 2 main (related) theoretical realms:
- Self-determination theory
- Motivation Interviewing techniques: the 5As. See more here.
This was shown to improve patient-reported adherence (not pain), but these were not maintained into 6 months. I think this small effect size is actually pretty encouraging given the HUMUNGOUS issue of behavioural change and this trial probably needs rolled out among a larger cohort. Communication, is the main tool of the health professional, and if used to address the factors listed above as ‘barriers’, then this is the best start to any outcome.
2. Building motivation to exercise
Chan et al 2009 (Ref) , designed a retrospective cohort (n=115), where participants were asked to recall their experience of ACL rehab and using algorithms they determined a level of therapist ‘autonomy-supportive’ behaviour; they demonstrated that when therapist behaviour was more autonomy-supportive, this had increased effect on motivation and subsequently (apparently adherence).
Beinart’s systematic review demonstrated that only one individual patient factor had moderate evidence to be associated with adherence:
- Higher health locus of control.
This fits with the above in so far as building motivation is linked to increasing self-efficacy and perceived control over their improvement. Higher motivation was associated with adherence to exercise, but had limited support and those with a stronger belief that others had control over their back pain exercised significantly less (Ref).
The above points demonstrate, that building intrinsic motivation to exercise in individuals, increases self-efficacy and gives the individual a perception that they can actually do some exercise. Herein, lies the crux of it; if you tell them they can do it, they may actually do some activity, and THEN they may do some of your home exercises as well! Halleluyah!
Supervision has been shown to be a very positive factor in improving exercise adherence (Ref , Ref ). I think this has been pretty well understood for a while, it generally crops up in most large reviews for any treatment intervention, and I am remiss to even mention this as the general gist of this post is to explore factors related to exercises you prescribe for patients when you can’t watch them, but this is important; supervise your patients doing their exercises, if only for a wee bit. It helps.
4. The art of the sell
If you can sell your program, and I mean really sell it, not just ‘promote’ it, then you can project an increase in uptake. I think more physiotherapists do need to understand more sales principles, we are a profession that has always been behind other professions like chiropractors and osteopaths in ‘the art of the deal’. And in turn, if more physios can use good sales technique, spend less time selling an individual treatment and more time selling self-management; well that seems like a world-changing idea to me. And in case you didn’t guess, no I don’t mean be more like Donald Trump; if we all did that the world will change for the absolute worst; just maybe sell the shit out your wares like only Trumpo knows best.
I think this is very underutilised; as an S&C I have the benefit of seeing things from two professional backgrounds. Physiotherapists are again, typically very poor at periodisation. Periodisation is the cycling of various aspects of a training program, or exercise regime. In S&C, variation of exercises, load, volume etc. etc. etc. is the key component to optimal physical performance; physiotherapists generally produce a horribly repetitive linear progressive overload with not much extra stimulus for the patient. If patients were exposed to more principles of periodisation in their home exercise programs, they would remain more interested and the ‘learning effect’ from mastering one exercise which links to their problematic movement, would cross over into their overall pain issue and promote more self-efficacy. For example when prescribing for shoulder pain with trouble through forward flexion and horizontal push patterns programming scapular push-ups is great, but periodising not only the sets and reps over your rehab program will help maintain motivation, but accessory exercises – like a cable paloff press – will help challenge the neural control mechanisms and enhance capacity in the movement.
Compliance; one of the biggest issues facing the musculoskeletal chronic pain burden on society. Inherently really very difficult to achieve for any treatment, but physiotherapy is evidently abysmal at it. So try more strategies, but remember, communication is key and motivation is king.