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Research Reports |
CA Thorstensson, PT, PhD, is Research Associate, Department of Research and Development, Spenshult Hospital for Rheumatic Diseases, Halmstad, Sweden
Address all correspondence to Dr Thorstensson at: carina.thorstensson{at}spenshult.se
Not only do physical therapists need to be updated on evidence-based medicine and best-available treatment, but, in some cases, they also need to market the treatment well enough to convince skeptical people to try it, not just once but repeatedly! Furthermore, it may be perceived as a nonpreferable treatment, requiring active participation, despite pain and discomfort. If we fail in our attempt to make the patient adherent, the best-available treatment will not help. Adherence is the key to our success.
As acknowledged by Grindley et al,1 there is not yet any "solution" to the adherence problem, even though multiple factors with an impact on adherence have been identified. The study by Grindley et al underscores the complex pattern of factors associated with adherence behavior, and the predictive value of the screening questionnaire used is limited. Thus, the problem is still to be solved.
Grindley et al categorize adherence into different subgroups: in-clinic adherence, as determined by the physical therapist; attendance at scheduled sessions; and dropping out of treatment without progress toward or achievement of the treatment goal. This commentary focuses on these categories and partly reflects my experience of working with people with chronic pain.
In-clinic adherence is defined by Grindley et al as the degree to which the patient meets the instructions and recommendations provided by the physical therapist. This type of adherence often is influenced by the patient's desire to please the physical therapist.2 However, the goal of in-clinic adherence is not just to mimic a movement. Grindley et al acknowledge that the patient's level of intelligence may be one crucial component to increase adherence and thereby treatment efficacy. This is not often spoken out loud, and it may be regarded as controversial, but I agree. To be able to understand and adhere to instructions, a certain level of cognition is required, as is a "connection" between brain and body, resulting in neuromuscular control. For example, a patient can drop down on a chair using gravity, more or less without muscular tonus of the quadriceps femoris muscle, or sit down using the eccentric contraction of the quadriceps femoris muscle to control the body's movement onto the chair. The performance depends not only on perceived pain, strength (force-generating capacity), and other physical factors, but also on cognition (ie, how the task is understood and interpreted). The patient's understanding may be influenced to a certain extent by didactic instructions, and that is just one reason why the instructions need to be careful and precise.
In-clinic adherence, however, is dependant on how the performance is "judged" by the physical therapist. This judgment can be difficult. A patient dropping down on a chair using gravity and immediately standing up again may appear to be more eager and to perform the exercise with more intensity than someone who uses the neuromuscular control through the range of movement. However, the eager performance may have an inverse affect on the outcome. In the "drop-down" performance, only eccentric contraction of the quadriceps femoris muscle is used, whereas in the controlled movement, both eccentric and concentric contractions of the quadriceps femoris muscle are used and at a slower speed and, therefore, involving more motor units. Furthermore, if the height of the sitting surface is adapted to the patient's ability, the muscle activity can be switched on through the entire range of movement. Adherence needs to incorporate not only intensity, frequency, and attention to changes in the rehabilitation program, but also—and most importantly—the quality of performance. This puts a great challenge on the patient but also on the physical therapist to provide feedback to help the patient understand the why and how. Five minutes of exercise using tasks of high neuromuscular quality may be as effective as 35 minutes of exercises of low or no neuromuscular quality. Perhaps we can reduce the often "standard" demands on the number of exercises included in rehabilitation programs, but increase the demands on the quality of the tasks performed. The shorter program might be easier for the patient to incorporate in everyday life, making the lack-of-time barrier easier to overcome. The best exercise is the one that is being performed.
Attendance at scheduled sessions is considered to be a prerequisite to success in any treatment. Grindley et al found that, even though the explanatory value was rather low, age and negative affect accounted for the greatest variance in attending the scheduled sessions. As discussed by the authors, people have different lifestyles and life situations at different ages, and it might be the lifestyle and life situation rather than age that determine the patient's attendance. Commitments that are difficult to reschedule might be more common at ages over 30 years.
If the patient does not "show up," it often is assumed that he or she does not pay enough attention to the treatment. However, research involving patients with arthritis has shown that their reasons for not attending physical therapy sessions are rational and understandable.2 The absence from treatment does not necessarily mean that patients do not care. They may, in fact, try their best while absent. During a trial comparing exercise twice a week for 6 weeks with no treatment for knee osteoarthritis, one man who was randomly assigned to the exercise group came only twice to the exercise sessions.3 I have to admit I was surprised when he arrived for the assessment, and I was even more surprised when he showed me his diary and told me about his diligent home exercises. He simply could not find the time to attend the exercise sessions, but he was clearly more motivated and hard-working than some of the patients who attended the exercise sessions. In the end, he contributed to a lower mean attendance score in the study, but I would not call him nonadherent.
According to the findings of the study by Grindley et al, dropping out of treatment without progress toward the treatment goal could be determined, in part, by affect (both positive and negative), severity, self-efficacy, and age. However, the predictive value of these factors was, as acknowledged by the authors, only slightly better than chance (60%). These are all factors influencing treatment preferences, and it seems obvious that preference is a strong determinant of adherence. Preferences are built on previous experiences and knowledge (ie, what patients have read or been told by others) and not always clearly expressed. Patients may have a strong pre-existing preference for a treatment that is not necessarily in accordance with best evidence, and the overall impact of preferences on adherence and treatment outcome is difficult to determine. They strive for the best possible outcome with the lowest possible "costs" (ie, investment of time, money, effort or unpleasant sensations such as pain). One of the most important goals for patients in the study by Grindley et al was complete recovery. The authors emphasize that thorough information and education about possible outcome are crucial to optimize expectations and achievable goals. If the patient believes that he or she will experience a rapid and complete recovery, a delayed response may cause frustration. In such a situation, dropping out of the prescribed rehabilitation program might be logical consequence of the patient's search for a more-effective treatment.
According to the protection motivation theory, as described by Grindley et al, the rehabilitation program would be perceived as desirable by patients if they understand the negative consequences and potential threat of not attending the rehabilitation sessions, such as the risk of increased pain or reduced function over time. In addition, the positive effects from exercise need to be understood, and preferably experienced, to act as motivators.4 There is no easy way to achieve positive effects from exercise. Speaking in positive terms about exercise and possible benefits from exercise may be perceived as invalid and maybe even provoking by patients with low body awareness and little or no previous experience with exercise (ie, "That's easy for her to say—what does she know about the pain I’m feeling?"). As described by Grindley et al, pain may actually reduce adherence. The temporarily increased pain often experienced during rehabilitation may be considered a reason for nonadherence (ie, fear avoidance).5 This is, from the patient's perspective, another rational decision, because the normal reaction to acute pain is to avoid what hurts and thereby avoid serious injury. However, a lot of our patients have pain that is no longer considered acute, and the behavior in response to other types of pain needs to be different and learned. Education regarding the type and level of pain that may be expected during and despite treatment is important. A somatic focus during the rehabilitation session is very common and sometimes is emphasized by questions on how it feels. As physical therapists, we can help patients identify and focus on realistic goals instead. Patients with rheumatoid arthritis who learned how to pay attention to a goal rather than to the pain and sensations felt from the body gained more pain relief from exercise.6
Adherence is a complex puzzle—crucial, challenging, and frustrating—and still a problem to solve.
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  E. J Grindley, S. J Zizzi, and A. M Nasypany Author Response Physical Therapy, December 1, 2008; 88(12): 1543 - 1544. [Full Text] [PDF]
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