“do words speak louder than actions?” or “do actions speak louder than words?” do therapists...

“Do words speak louder than actions?” OR “Do actions speak louder than words?”

Do therapists actions facilitate or discourage patient adherence?

Sionnadh McLean

Sheffield Hallam University-Physiotherapy exercise course 2014

Setting the scene – exercise adherence/attendance

Actions which influence exercise adherence

Strategies to improve rehabilitation adherence???

Actions to improve rehabilitation adherence

Aims

Exercise is generally considered to be appropriate for most MSK conditions.

Improvements in the range 5-12% are commonly reported

One type of exercise is usually not more effective than other forms of exercise.

Exercise is usually not more effective than other treatments.

Short-term effects of exercise commonly decline over time.

Summary: Exercise is usually effective


Studies suggest that non-adherence with exercise could be as high as 70% (Sluijs et al., 1993); usually around 50%

Particularly poor for unsupervised home exercise programmes (Reilly et al., 1989; Nelson et al., 1995).

Non-attendance at appointments - 9% to 46% in some services. (Alexandre et al 2002; Funch & Gale 1986).

A few statistics about non-adherence


Actions speak louder than words?

Transtheoretical Model of behaviour change assesses an individual's readiness to act on a new healthier behaviour AKA “Stages of Change” model (Prochaska & DiClimente 1977)

Do we assume too much?


Rational Choice Theory

Simply put – Cost v Benefit analysis

Staying the same

Making a change


Rational choice theory

Do we understand patient’s decision making?

Staying the same

Taking action


poor social support

low self-motivation external locus of

control (Ahuja et al, submitted to APMR)

Predictors of non-adherence (in-clinic)

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://mylifeintupperware.blogspot.com/2012/01/new-years-resolution.html&ei=i052VL7FJonUarjwgNAM&bvm=bv.80642063,d.d2s&psig=AFQjCNFJcCiYZFIETiHVASwesKHDCDESlA&ust=1417125874292547


low in-treatment adherence with exercise, decreased satisfaction with

physiotherapist, increased pain levels during exercise, poor social support, sedentary lifestyle, low self-motivation,

(Ahuja et al, submitted to APMR)

Predictors of non-adherence (HEP)


More Actions: A qualitative synthesis

(Ahuja et al, in preparation)


Strategies for increasing adherence with exercise recommendations

There was conflicting evidence that adherence interventions increase short-term adherence with exercise.

There was strong evidence that adherence strategies are not effective at improving long-term adherence with home exercise.

Due to the multi-dimensional nature of non-adherence, the strategies to improve adherence are likely to be broad in spectrum.

(McLean et al 2010)


Patients must believe that the prescribed exercise will work for them

Within session changes predict longer term treatment outcome. (Hahne et al 2004; Tuttle 2005)

Exercise should fit in with the patients lifestyle AND be welcome

Exercises should be meaningful

“Actions which may speak louder than words”


Consider whether exercise should be hell!!

Anxiety, distress etc may significantly increase levels of Delayed Onset Muscle Soreness (Bishop et al 2011; Goodin and McGuire 2009)

Be considerate about your starting point for exercise

Spend time with patients on the exercise programme.

“Actions which may speak louder than words” – BE CONSIDERATE

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=66gywb0-ydusjM&tbnid=0Ew1j9ZKHVcv3M:&ved=0CAUQjRw&url=http://livingwithra-nan.blogspot.com/2011/07/no-pain-no-gain-not.html&ei=-OMVU8fGFNSM7AbuwoD4AQ&bvm=bv.62286460,d.ZGU&psig=AFQjCNGSpWvFgoCTLyJ0s8zivzYzh3qNPA&ust=1394029935184020


Sluijs EM, Kok GJ, van der Zee J. Correlates of exercise compliance in physical therapy. Physical Therapy 1993;73(11):771-82.

Reilly K, Lovejoy B, Williams R, Roth H. Differences between a supervised and independent strength and conditioning program with chronic low back syndromes. Journal of Occupational Medicine 1989;31(6):547-50.

Nelson BW, O’Reilly E, Miller M, Hogan M, Wegner JA, Kelly C. The clinical effects of intensive, specific exercise on chronic low back pain: a controlled study of 895 consecutive patients with 1-year follow up. Orthopedics 1995;18(10):971-81.

Neubeck L et al 2012 Participating in cardiac rehabilitation: a systematic review and meta-synthesis of qualitative data. European Journal of Preventive Cardiology 2012;19:494–503

Keating A, Lee A, Holland AE. What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review. Chronic Respiratory Disease 8(2) 89–99

Jack K, McLean SM, Klaber Moffett JA, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Manual Therapy 2010;15(3):220-8.

Bishop MD, Horn ME, George SZ. Exercise-induced pain intensity predicted by pre-exercise fear of pain and pain sensitivity. Clinical Journal of Pain 2011;27:398–404

Goodin BR et al Pain catastrophizing mediates the relationship between self-reported strenuous exercise involvement and pain ratings: Moderating role of anxiety sensitivity. Psychosomatic Medicine 2009;71:1018–1025

References


Alexandre NM et al (2002). Predictors of compliance with short-term treatment among patients with back pain. Pan American journal of public health, 12(2):86-94.

Funch DP, Gale EN (1986). Predicting treatment completion in a behavioral therapy program for chronic temporomandibular pain. Journal of psychosomatic research, 30(1):57-62.

Prochaska JO; DiClemente CC (2005) The transtheoretical approach. In: Norcross, JC; Goldfried, MR. (eds.) Handbook of psychotherapy integration. 2nd ed. New York: Oxford University Press; p. 147–171.

Hahne AJ, Keating JL et al (2004) Do within session changes in pain intensity and range of motion predict between session changes in patients with LBP. Australian Journal of Physiotherapy 50: 17-23

Tuttle N (2005) Do changes within a manual therapy treatment session predict between-session changes for patients with cervical spine pain? Australian Journal of Physiotherapy 51: 43–48

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