<LEAP> highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness and appropriateness of interventions—medications, surgery, education, nutrition, exercise—and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature.1 Each article in this PTJ series will summarize a Cochrane review or other scientific evidence resource on a single topic and will present clinical scenarios based on real patients to illustrate how the results of the review can be used to directly inform clinical decisions. This article focuses on exercise adherence interventions among adults with chronic musculoskeletal pain. Which, if any, approaches foster exercise adherence among adults with chronic musculoskeletal pain?
Physical activity and progressive resistance training exercises are increasingly accepted as effective interventions for people with knee and hip osteoarthritis2–6 and chronic low back pain,7 with several systematic reviews showing physical activity and progressive resistance training exercises have small to moderate beneficial effects on pain and functional activity.8–15 The beneficial effects achieved with physical activity and exercise, however, diminish as activity is ceased—as is frequently observed when intervention programs are terminated.
The 2008 Physical Activity Guidelines for Americans suggest that, on average, adults with chronic musculoskeletal conditions should engage in 150 minutes of moderate, low-impact activity (eg, walking, swimming, biking) per week and resistance training of major muscle groups 2 days per week.6,16 Adherence to these guidelines, however, is poor, with few older adults with chronic musculoskeletal conditions meeting recommendations for aerobic activity and strength training.17,18
Physical therapists are in a unique position to make a significant impact in the field of physical activity adherence. Unlike many health providers and health researchers, physical therapists frequently conduct several treatment sessions in a relatively short time that focus on prescribing specific therapeutic exercises, which often result in some reduction in pain and improvement in function, at least in the short term. These positive results can provide an opportunity to foster adherence.
Yet, how can physical therapists address physical activity adherence in the context of clinical care? Which strategies are effective at promoting adherence to physical activity and exercise? Jordan and colleagues' systematic review19 on evidence-based physical activity adherence strategies addresses the literature relevant to these questions and identifies areas for further development in this topic.
The systematic review by Jordan et al19 included 42 studies and 8,243 participants (Appendix). Due to high heterogeneity of the data, qualitative methods (ie, counting positive adherence outcomes) were used in lieu of meta-analytic statistical procedures, which may limit the validity of the results. Furthermore, only 43% of the studies had a beneficial impact on adherence, suggesting interventions to date have a modest effect on adherence. Lastly, the use of multiple interventions within individual studies made it difficult to interpret which strategies are effective, and follow-up outcome assessment was varied, limiting the ability to determine the impact of these strategies on long-term adherence. Thus, caution should be used when making strong conclusions regarding which strategies are most effective based on this study.
Nonetheless, some important trends in type, delivery, and adherence components of programs were noted. First, mode of exercise (eg, aerobic versus resistance, back-specific versus general exercise) had no relationship to adherence. Thus, we suggest using patient preference to guide selection of the type of exercise activities. For example, patient preference could guide selection of low-impact walking in a mall versus low-impact walking around the neighborhood or strength training with Thera-Band tubing (The Hygenic Corporation, Akron, Ohio) versus strength training at a gym. Supporting patient preference, however, assumes that the patient is able to choose safe and effective exercise options. That is, for some patients, low-impact walking and back stabilization exercises may be essential aspects of low back pain management, whereas high-impact jumping activities may be detrimental. As long as patients are choosing activities that are likely to benefit their health, patient preference should be used as a guide.
Alternatively, the manner in which programs are delivered may affect adherence. Programs delivered in a supervised manner may have a greater impact on adherence than those delivered in an unsupervised manner. Individual programming seems better than home exercise alone, and home exercise plus group exercise programs may have a greater impact on adherence than home exercise alone. Finally, group exercise programs, if convenient, should be considered, particularly if a patient prefers this approach. In addition to having beneficial effects on adherence, pain, and function, group exercise programs can promote social support and “buddy systems,” both of which have been linked to better physical activity adherence and maintenance.20,21
Self-management education approaches (ie, approaches that emphasize education regarding disease pathology and symptom management, nutrition, weight management, joint protection, coping, relaxation, and physical activity instruction) seem to positively affect exercise adherence, although the majority of the studies examining self-management approaches were based on the arthritis self-management program developed by Lorig and colleagues.22,23 The impact of self-management education on clinical outcomes of pain, function, and quality of life is not clear because the majority of studies in this review did not show improvement in clinical outcomes. Behavior change strategies, including goal setting, feedback, and contracting, also were found to be effective, whereas the evidence supporting cognitive-behavioral approaches was limited.
Case #12: Applying Evidence to a Patient With Symptomatic (ie, Painful) Knee Osteoarthritis
Which, if any, strategies could promote exercise adherence with this patient?
Ms Miller is a 60-year-old choir director who has been going to physical therapy to address knee pain related to osteoarthritis. Ms Miller was diagnosed with osteoarthritis 10 years previously but has had increased difficulty standing during her job within the past year. The physical therapist decided to administer the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a valid and reliable tool for assessing pain and functional outcomes in people with knee osteoarthritis that has 3 subscales (physical function, pain, and stiffness).24 Ms Miller's WOMAC physical function score at the beginning of physical therapy was 28 (scale range: 0–68), and she rated her pain as 7 on a 10-point pain visual analog scale. By the end of therapy, her WOMAC physical function score had improved to 15 and her pain score had decreased to 2/10, with both scores indicating clinically meaningful change.25
Having reached her goals of pain and function, Ms Miller is being discharged from physical therapy but would benefit from continued exercise in the future. Ms Miller has not participated in regular exercise before and expresses concern with how to go about starting a program. The therapist's goal for Ms Miller was for her to meet the current Centers for Disease Control and Prevention's (CDC's) recommended levels of physical activity for people with chronic musculoskeletal conditions: 150 minutes of moderate, low-impact activity per week; strength training twice a week.6,16
How did the results of the Cochrane Systematic Review apply to Ms Miller?
Ms Miller's therapist posed the clinical question: What are the best strategies to improve exercise adherence in a 60-year-old woman with chronic pain related to knee osteoarthritis? A literature search identified the Cochrane review by Jordan et al,19 and using the PICO (Patient, Intervention, Comparison, Outcome) approach, the therapist asked:
What is the population of interest in the study?
What is the main intervention or therapy considered?
Is there an alternative treatment option?
What are the clinical outcomes?
The population in the review included adults, both male and female, with chronic conditions, which matches the patient. Although the review by Jordan et al19 does not specifically target women or Ms Miller's age group, it includes her demographics and, therefore, is applicable.
Based on the review by Jordan et al,19 the physical therapist offered evidence-based advice to his patient. Ms Miller was receiving supervised, individualized physical therapy, which is consistent with the recommendations of the review. In the last 2 weeks of physical therapy, the physical therapist used activity logs (ie, forms that document type, duration, and intensity of exercise activities over a specified time, usually a week) and started an exercise contract (a structured goal-setting activity in which people specify a goal and sign a document acknowledging intent to achieve the goal) with Ms Miller. He had several in-depth discussions with her about the importance of continuing exercise and discussed community-based group and individualized exercise programs offered in her area, emphasizing that the important aspect for Ms Miller to consider is whether a group exercise program or an individualized program is her personal preference. He also provided information on a local arthritis self-management and exercise program and encouraged Ms Miller to participate.
The alternative treatment for this situation is to not address physical activity adherence for Ms Miller. Given the evidence and the likelihood that promoting adherence would not adversely affect the patient, the alternative treatment is not optimal.
The review concludes that the manner in which programs are delivered, as well as the inclusion of strategies to foster adherence beyond the structured exercise program (additional educational material, goal setting, self-management practices), may foster adherence among people with chronic musculoskeletal pain. Although it gives several types of adherence strategies, it does not provide clear guidance on which type is most effective or how to implement these strategies. Thus, for the therapist treating Ms Miller, it was a starting point for ideas to improve adherence but required additional steps to implement. Recommending specific strategies relies on a physical therapist's clinical judgment, knowledge of local resources, and exposure to relevant adherence literature and continuing education materials. Readers interested in information on feedback, goal setting, contracts, and self-management are referred to several articles for further review.26–29
How well do the outcomes of the intervention provided to Ms Miller match those suggested by the systematic review?
On the last day of treatment, the therapist reviewed Ms Miller's activity logs and exercise contracts. Ms Miller completed the suggested adherence strategies and, therefore, was adherent to the behavior change recommendations over the 2-week period. Her activity logs showed she was engaging in 20 minutes of moderate activity on 5 out of the past 7 days. Thus, she had improved her activity from sedentary to more active, although she currently did not meet the CDC's recommendations of 150 minutes of moderate exercise per week. Nonetheless, she was showing good progress with the recommended exercise activity. If further follow-up is possible, it could be beneficial for the therapist to further evaluate her progress with exercise adherence.
Can you apply the results of the systematic review to your own patients?
There are some important generalization limitations of this systematic review that should be considered when applying the study findings broadly to patients in physical therapist practice. First, the studies in the review were highly heterogeneous, using mixed sampling methods and varied intervention approaches. Few studies examined adherence strategies in the context of physical therapy intervention, and many of the findings were inconsistent. Second, study quality was limited, and ascertaining adherence was sometimes problematic.
What can be advised based on the results of this systematic review?
Although the study does have some internal and external limitations, there are some findings that warrant consideration. The article by Jordan et al19 provides a detailed review of the studies and potential interventions to improve adherence to physical activity that would be well worth implementing in practice. Many of the strategies recommended do not require costly resources (ie, equipment, training, or time) and could easily be implemented in the clinical setting. Furthermore, the strategies recommended are not likely to cause any harm to individuals, and if the strategies are implemented and the goal is achieved (ie, engaging in regular physical activity), outcomes would likely be positive. Physical therapists increasingly strive to have their patients sustain benefits made during treatment when they are discharged to independent home programs, and fostering adherence among patients is critical.
Addressing physical activity adherence within the clinical context may be new for some therapists. Information utilizing goal setting and contracting to promote adherence is available.26–29 Likewise, evidence-based physical activity and self-management education programs, such as those recommended by the CDC,30 are available in many communities, including: (1) the Arthritis Foundation Exercise Program, (2) Active Living Everyday, (3) the Arthritis Foundation Aquatic Program, (4) EnhanceFitness, (5) Fit and Strong, (6) Walk With Ease, (7) the Arthritis Self-management Program, and (8) the Chronic Disease Self-management Program. In addition, many recreational centers offer supportive environments that may enhance adherence, and referrals to these community resources may be beneficial to patients. Recommendations to evidence-based programs could be a nice complement to home discharge programs as a means to enhance adherence. Nevertheless, more research is clearly needed. In particular, improved study methods, particularly efforts to decrease threats to validity and generalizability, are critical to establishing a strong effect on adherence.
This study was supported by the US Department of Education, National Institute on Disability and Rehabilitation Research.
- Received May 3, 2011.
- Accepted August 1, 2012.
- © 2013 American Physical Therapy Association