From: BMC Health Serv Res. 2010 Mar 10;10(1):60. [Epub ahead of print]
Neck and low back pain are prevalent and they are the major cause of work disability, being responsible for high costs to society. Recurrence of neck and low back pain are common and their course is variable, with 10-15% of cases leading to chronic pain. Exercise therapy commonly forms part of the treatment prescribed by care providers to patients presenting low back or neck pain. Systematic reviews have concluded that exercise appears to be effective in decreasing pain and improving function. Exercises are often instructed individually and prescribed to be performed at home. Although home-based exercises vary greatly in the method of delivery and content, different programs appear to have similar effects on patients.
Scientific evidence suggests that inadequate adherence to home-based exercises may attenuate the treatment’s efficacy. It has also been proposed that many recurrent cases of low back pain could have been avoided if patients had adhered to their home programs. Nevertheless, several studies reported that adherence to exercise is often a serious issue for patients with neck or low back pain. Differences in the definition of adherence used, measurement and estimative of how many patients do not comply with their prescribed exercises vary, but evidence converge on a figure of 50% or higher.
Research suggests that certain conducts of care-provider, such as giving patients positive incentives, giving feedback about their progress and treatment, or monitoring their exercise performance, they all influence in the adherence to home exercise programs. In addition, other studies also evidenced that patients usually experience some intrinsic factors which are understood to bring difficulties in the performance of home-based exercises. The most common factors are the lack of time to exercise, and the inability to fit the exercises into their daily routine.
Most of those studies investigating the influences of patients’ adherence employed highly structured questionnaires intended to obtain responses to questions that the researchers had previously identified to be relevant. Although a few qualitative studies have studied these factors from the perspective of lower back pain patients, no study to date have explored the factors related to patient-provider issues.
Despite the fact that previous studies explored the role of care provider’s conduct and the content of home-based exercise programs towards the patients’ compliance with prescribed exercises, further investigation is needed to understand which aspects of home-based programs and clinical settings may increase adherence to prescribed exercises for low back pain or exercises for neck pain in the patient population. This issue, explored from the patients’ perspective, is important due to the fact that many patients exercising because of chronic pain usually make active decisions about their own exercises, rather than being simply passive recipients of health care.
The aim of this study was to explore how the intrinsic characteristics of home-based exercise program or care provider’ style in clinical settings affects chronic neck or low back pain patients’ adherence to prescribed exercise.
The results of this study demonstrate that some conducts of care provider and the contents of home-based exercise programs were both important on participant’s adherence to the program. Care provider’s style and home-based exercise program conditions emerged as strong themes in the data.
Home-based exercise programs are known to interfere with normal life and requires interruption of daily routine. The current study study is consistent with this statement, and evidences that participants presenting chronic neck or back pain decline more to adhere to prescribed home exercises when the home program requires longer time for execution or includes exercises which are difficult to perform. Minimizing the interruption caused by exercising on daily routine may provide one solution to the poor adherence problem. One solution would be limiting the number of exercises prescribed in each program. Similarly, there is evidence suggesting that more than eight exercises in a program play a negative influence on participant’s adherence to prescribed exercises.
High levels of participant adherence have been closely related to their own perception of program’s benefits. The influence of these benefits on participant’s performance is an issue that supports the social cognitive theory. This study added empirical evidence that these benefits have a limited effect on participant’s adherence until the point where participants have achieved their aimed outcomes. Therefore, it is recommendable that, when symptoms are absent, additional incentives should be provided in order to prevent recurrences. For that reason, the consistent use of outcome measures, such as number of exercise repetition, endurance, or heart rate, would offer participants a sense of progress. Knowing their own progress could offer them a sense of active control over their own health, which in turn, would be worthwhile when facing more important activities.
When adverse effects were perceived while performing the exercises, the participants naturally responded with a poor-adherence to the prescribed home program. Patients suffering from knee osteoarthritis presented a similar response to exercise’s adverse effects. Similarly, pain increase has been suggested to contribute to low adherence rates, in accordance with a fear-avoidance model of inactivity. Minimizing the pain and the fear associated to exercising must be a priority concern of care providers. In a review, Masters and Ogles proposed that the use of entertainment while exercising can minimize sensation of discomfort and can improve participant’s adherence. This study suggests that a proper supervision during the exercise execution for the duration of session may be an additional element to reduce patients’ insecurity and fear of exercising at home.
The findings on the subject of how care provider’s style is important for participant’s adherence to home-based exercise program confirm and extend previous findings. The participants in this study recognized that a supervised instruction which includes proper feedback was important for their adherence. It is evidenced that exercises based only on written instructions are not often performed properly, and therefore lead to poorer outcomes than when compared with outcomes from exercises learned under the supervision of a care provider. Nevertheless, there is also evidence that an interactive exercise mode combined with written instructions improves adherence to exercises of patients presenting back pain.
Written instructions or exercising during specific daily activities were usually used as reminders for the participants. The participants in this study often felt that these reminders were important. In a same way, the use of reminders has also been recommended by relevant studies, due to the fact that patients tend to forget exercising or have serious difficulties in fitting the exercises into their daily routine.
This study demonstrated that what the care provider says when giving the exercise instruction is relevant for the patient’s own decision-making process. In contrast, some author believes that offering information and justifying the efficacy of the treatment to patients, are not enough practice to manage successful treatment adherence in patients presenting chronic pain. The authors considered that the efficacy of the information provided depends on whether or not it connects with the patients’ beliefs and expectations. This is a central recommendation within the assessment of the bio-psycho-social model. There is a wide literature on the subject of this model which is useful to strengthen treatment.
This study has been used to identify some of the connections between participant’s experiences, their own perceptions, and their adherence behaviour. The results presented an insight into which factors the care provider shall consider in order to optimize participant’s adherence when prescribing home-based exercises.
The strength of this study lies in the use of qualitative methodology to obtain a description of patients’ experiences, the use of rigorous methods, and the use of an objective sampling frame and the selection of one heterogeneous sampling. This last issue suggests that results could be representative of the experience of patients with chronic neck or back pain.
This study’s subjects highlighted that adherence to treatment was poor when exercises were time consuming or when the program interrupted the participant’s daily routine. Additional issues which can difficult adherence were identified, such as time consumption, complexity and adverse effects of exercises, and some care provider’s styles. The results suggest that participant are most likely to adhere to home-based exercises when their care provider provides proper feedback and gives reminders during the supervised execution of exercises, and when the participants perceive the benefits of exercises on their pain status. Other important factors which can affect adherence to treatment are: the way in which the prescribed exercises are designed, the degree of difficulty of the exercises, and how the program is delivered by the care provider. These findings provide additional information to health care providers, by showing which issues should be considered when delivering health care to patients presenting chronic neck or back pain.
