Evidence Based Techniques To Improve Patient Compliance

INTRODUCTION

As sports physiotherapists we readily prescribe exercise programs to our athletes/patients – quite simply – it is a massive part of what we do. As well as exercises, we also tell our patients what they should NOT be doing – “You should not do this OR that”! Have you ever wondered how much they really take our advice? Unfortunately (for both us and the patient) our patients are frequently non-compliant with our rehabilitation programs. In fact, it has been reported that compliance with exercise programs is generally 30 – 57%, and this dramatically decreases with time (Sluijs & Knibbe, 1991).

The cynics out there might suggest why do we even bother? Fairly obviously it is important that we do bother! Exercise is frequently our most evidence based intervention. Thus, we should ensure that we are doing everything to improve the compliance of patients, so here are some evidence based tips to improve patient compliance!

WRITTEN EXERCISE PROGRAMS

The provision of written exercise programs, as opposed to verbal instructions, was found to improve short-term compliance (2 weeks) with a home exercise program in patients with acute to sub-acute low back pain (McLean et al., 2010). Additionally, I would suggest that written exercise programs would likely improve the patient’s recollection of technique and exercise prescription (sets, reps and holds). Get it done!

INDIVIDUALISED AND REFRESHED EXERCISES

I don’t even think that I need to discuss the importance of individualised exercises – surely. It is also important, however, to refresh the patient’s understanding of these exercises with a few refresher sessions. Harkapaa et al. (1990) found improved compliance in patients who underwent “refresher sessions” compared with written and verbal instructions.

GOAL SETTING

Levack et al. (2006) performed a systematic review to assess the effectiveness of goal planning and setting. Unfortunately, they found limited evidence for the use of goal planning/setting in improving compliance in musculoskeletal physiotherapy. They did, however, find significant support for its use in an acquired brain injury population. Lack of support for goal-setting was also found by Bassett and Petrie (1999), with no significant difference in compliance between goal setting groups and controls.

Despite this, I would still recommend the use of goal setting for your patients. Collaborative goal setting allows a clear clinical pathway for you and more importantly your patients. After all, you have to make sure that you are both aiming for the same set of goal posts.

COGNITIVE-BEHAVIOURAL THERAPY

McLean et al. (2010) found that CBT, including cognitive behavioural reinforcement and a motivational programme, to be effective at increasing short-term compliance with exercises. However, these gains are not retained in the long-term i.e. greater than 6 months.

COMMUNICATION

Now this is a pretty simple one, however, one that is challenging to assess in a scientific setting. Communication with the patient is absolutely essential to encourage compliance with proposed actions and exercise programs. It is imperative that the patient has a clear understanding of their diagnosis (in simplest form), prognosis, contributing factors, and what can be done about it (i.e. exercise therapy). Within these open lines of communication you can also identify (and hopefully remove) barriers to compliance and challenge harmful beliefs e.g. fear avoidance. This will develop higher levels of rapport with the patient, and hopefully (fingers crossed) improve their compliance!

THINGS THAT DID NOT MAKE THE CUT

There were a few interventions in the research that did not make the cut, as they did not deliver significant improvements in compliance over control groups. This included contracts between the patient and practitioner (Bosch-Capblanch et al., 2007), individualised exercise videos (however – I bet they do impress people) (Lysack et al.,2005), and counseling (Basler et al. 2007).

TAKE HOME MESSAGES

Write down the exercises
Refresh them regularly
Set collaborative goals
Get in the patient’s head (with CBT)
Communicate like a champ

However, as always there is a but. There are issues with the above research, and it displays massive heterogeneity. I would argue that our key demographic, athletes, are more compliant than the general population, and few studies evaluate this population. Remember this…

Tell me – what are your experiences with improving the compliance of patients? What little tips and tricks do you use that work? Let me know in the comments or catch me on Facebook or Twitter

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REFERENCES

Basler HD, Bertalanffy H, Quint S, Wilke A, Wolf U. TTM-based counselling in physiotherapy does not contribute to an increase of adherence to activity recommendations in older adults with chronic low back pain–a randomised controlled trial. European Journal of Pain 2007;11(1):31–7.

Bassett SF, Petrie KJ. The Effect of Treatment Goals on Patient Compliance with Physiotherapy Exercise Programmes. Physiotherapy 1999;85(3):130-137

Bosch-Capblanch X, Abba K, Prictor M, Garner P. Contracts between patients and healthcare practitioners for improving patients’ adherence to treatment, prevention and health promotion activities. Cochrane Database of Systematic Reviews 2007, Issue 2.

Friedrich M, Cermak T, Maderbacher P. The effect of brochure use versus therapist teaching on patients performing therapeutic exercise and on changes in impairment status. Physical Therapy 1996;76(10):1082–8.

Harkapaa K, Mellin G, Jarvikoski A, Hurri H. A controlled study on the outcome of inpatient and outpatient treatment of low back pain. Part III. Long-term follow-up of pain, disability, and compliance. Scandinavian Journal of Rehabilitation Medicine 1990; 22(4):181–8.

Levack WMM, Taylor K, Siegert RJ, Dean SG. Is goal planning in rehabilitation effective? A systematic review. Clinical Rehabilitation 2006; 20: 739-755

Luszczynska A, Gregajtys A, Abraham C. Effects of a self-efficacy intervention on initiation of recommended exercises in patients with spondylosis. Journal of Aging and Physical Activity 2007;15: 26–40.

Lysack C, Dama M, Neufeld S, Andreassi E. A compliance and satisfaction with home exercise: a comparison of computer-assisted video instruction and routine rehabilitation practice. Journal of Allied Health 2005;34(2):76e82.

McLean, S., Burton, M., Bradley, L., & Littlewood, C. (2010). Interventions for enhancing adherence with physiotherapy: a systematic review. Manual Therapy, 15(6), 514-21.

Sluijs EM, Knibbe JJ. Patient Compliance with Exercise: Different Theoretical Approaches to Short-Term and Long-Term Compliance Patient Education and Counseling, 11 (1991) 191-204