While the benefits of exercise have been well established, there is case study evidence to show that the subsequent adherence to home exercise programs (HEPs) in rehabilitation is a significant problem, and the reasons for this are multifactorial, covering both psychological and situational factors that vary between each individual, and that need to be considered by clinicians in the design of personalized exercise programs.
Home exercise programs are critical for treatment success
In order to provide the best possible individualized home exercise program (HEP) to their patients, physicians need to understand the dynamics of adherence to HEPs.
A 2014 study_[1]_ found evidence that patients who adhere to their prescribed exercises are significantly better at achieving their goals and demonstrate a greater increase in physical function. The authors conclude that "adherence is an important pre-requisite for...[the] success" of home exercise programs.
A study of the effect of adherence to a home exercise program on physical function in patients with chronic low back pain, published in the Journal of Manual and Manipulative Therapy_[2]_, has shown that those who adhere to their prescribed exercises are significantly better at achieving their goals and demonstrate a greater increase in physical function.
Home exercise adherence rates are poor
The researchers found that non-adherence to home exercise programs is common among patients with chronic low back pain. However, they also found that adherence is associated with better outcomes when compared to those who do not adhere_[3][4][5]_. In addition, they found that patients who adhere to their prescribed exercises demonstrate improved outcomes regardless of whether they were prescribed dynamic or static exercises or whether they had an acute or chronic condition.
Adherence to home exercise programs has been a topic of study for decades. The evidence base for different types of home exercise programs is broad, with a range of physical activity interventions being used in clinical practice. However, most studies report that 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_[6]_. This is particularly worrying when considering the high prevalence of musculoskeletal pain in MSK conditions and its impact on quality of life and function. Adherence rates tend to be higher when an exercise prescription is combined with another intervention such as education or self-management support; however, even these interventions achieve only modest adherence rates (20-30%).
Common reasons for non-adherence
The reasons for non-adherence may vary depending on the type of intervention but typically include:
- Lack of time (i.e., too much work)
- Lack of motivation/perceived benefit
- Perceived lack of control over treatment plan (e.g., being told what exercises to do rather than having choice)
Non-compliance with a HEP raises the chance of repeated injury or flare-ups, resulting in less favourable long-term outcomes_[7]_ and leading the physiotherapist to believe that their present treatment is ineffective_[8]_.
Fixing the problem at the root
Adherence can be increased by:
Patient education
This includes explaining the rationale behind the exercises, what they should do and how often they should do them. In addition, information about how an exercise program fits into their lifestyle needs to be provided.
Treatment for pain
Treatment of pain may reduce pain-related fear avoidance behaviours that prevent patients from exercising at home.
Personalised approach
Tailoring the program to each patient's specific needs will improve adherence and motivation to complete exercises at home. Therapists can provide patients with pictures and videos of themselves performing the prescribed exercises, to help them feel more involved in the treatment and to boost their confidence.
Takeaway
The above recommendations highlight several ways to improve adherence to HEPs. The key is to understand the patient's motivation for exercise and tailor interventions in a way that enhances the patient's experience, thereby maximizing successful behaviour change. Successful adherence to a home exercise program requires the collaborative effort of patient and clinician. Clinicians and patient should work together to develop an effective home exercise program plan.
If you'd like to find out more about how Extensor is helping physiotherapists around the world improve their patients' adherence to their home exercise programs, visit www.extensor.app.
Sources
[1] Holden, M.A., Haywood, K.L., Potia, T.A. et al. Recommendations for exercise adherence measures in musculoskeletal settings: a systematic review and consensus meeting (protocol). Syst Rev3, 10 (2014). https://doi.org/10.1186/2046-4053-3-10
[2] The Journal of Manual & Manipulative Therapy Vol. 11 No. 2 (2003), 78 - 87
[3] Di Fabio RP, Mackey G, Holte JB. Disability and functional status in patients with low back pain receiving workers' compensation: a descriptive study with implications for the efficacy of physical therapy. Physical Therapy. 1995 Mar 1;75(3):180-93.
[4] Pinto BM, Rabin C, Dunsiger S. Home‐based exercise among cancer survivors: adherence and its predictors. Psycho‐Oncology: Journal of the Psychological, Social and Behavioral Dimensions of Cancer. 2009 Apr;18(4):369-76
[5] Karnad P, McLean S. Physiotherapists’ perceptions of patient adherence to home exercises in chronic musculoskeletal rehabilitation. International Journal of Physiotherapy. 2011 Jun;1(2):14-29
[6] Bassett SF. The assessment of patient adherence to physiotherapy rehabilitation. NZ J Physiother, 2003, 31: 60–66
[7] Jack K, McLean SM, Moffett JK, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. Manual Therapy, 2010, 15: 220–228
[8] Wright BJ, Galtieri NJ, Fell M. Non-adherence to prescribed home rehabilitation exercises for musculoskeletal injuries: the role of the patient- practitioner relationship. J Rehabil Med, 2014, 46: 153–158
