The assessment of patient adherence to physiotherapy rehabilitation.
Physical therapy (Physiological aspects)
Physical therapy (Research)
Therapeutics, Physiological (Health aspects)
Therapeutics, Physiological (Physiological aspects)
Therapeutics, Physiological (Research)
Patients (Care and treatment)
|Author:||Bassett, Sandra Frances|
|Publication:||Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2003 New Zealand Society of Physiotherapists ISSN: 0303-7193|
|Issue:||Date: July, 2003 Source Volume: 31 Source Issue: 2|
|Topic:||Event Code: 310 Science & research|
|Geographic:||Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand|
This paper discusses the problem of adherence in physiotherapy and methods of assessing it. Poor adherence to physiotherapy is a problem with up to 65% of patients being either nonadherent or partially adherent to their home programmes, and approximately 10% of patients failing to complete their prescribed course of physiotherapy. As physiotherapy programmes consist of a diverse range of treatment methods that may be administered either at the clinic or at home, the measurement of adherence to these components must reflect the behavioural demands that each impose. Attendance at physiotherapy and the use of the Sport Injury Rehabilitation Adherence Scale (SIRAS: Brewer et al., 1995) to assess patients' behaviours during the treatment session are recommended as the measures of clinic-based adherence. Patient self-reports are suggested as the most ideal method of evaluating adherence to the home-based physiotherapy. Any assessment of adherence must also include an analysis of the reasons for this type of behaviour, which tend to be related to the patients' personal characteristics, variables related to the disease or injury and treatment, and the patient-physiotherapist interaction. Knowing the reasons for poor adherence will assist physiotherapists in finding solutions to overcome the problem. Sandra Frances Bassett (2003). The Assessment of Patient Adherence to Physiotherapy Rehabilitation. New Zealand Journal of Physiotherapy 31(2): 60-66.
Key words: patient adherence, physiotherapy, measurement of adherence, determinants of adherence
A problem frequently faced by physiotherapists is that patients may fail to recover from their injury in spite of there being no apparent pathological basis for this poor outcome. This may lead physiotherapists to wrongly think the treatment programme is not fulfilling the needs of the patients; a decision that is based solely on their physical status. However, had the patients' psychological and behavioural responses to their injury and treatment been taken into account then it is possible poor treatment adherence might have been detected. The degree to which patients adhere to the clinic- and home-based treatment requirements is considered to be responsible in some part for the success of physiotherapy programmes (Codori et al, 1992; Sluijs et al., 1998). Further it is recognised that the patients' perceptions about their injuries, resultant symptoms and the coping mechanisms are influential in determining the level of rehabilitation adherence (Brewer, 1999). Undetected non-adherence is a reason for treatment programmes being unnecessarily altered, and it has even been suggested to be responsible to some extent for non-significant research outcomes in clinical based research (Turk and Rudy, 1991).
This paper will discuss patient adherence to physiotherapy with reference to its occurrence, measurement and determining factors, and will conclude by providing recommendations about how physiotherapists can identify patients who might be having problems adhering to their treatment programme. As there is only a small amount of empirical evidence about adherence to physiotherapy, this paper has drawn on relevant literature from other rehabilitation disciplines. The definition of adherence underpinning the discussion has been adapted from that posited by Meichenbaum and Turk (1987) and is 'the extent to which the patients undertake the clinic-based and home-based prescribed components of their physiotherapy programme'. Adherence is used in preference to compliance because it is considered to imply active voluntary involvement of the patients in the planning and implementation of the treatment, whereas compliance is regarded as abiding obediently by the practitioner's prescribed treatment protocol (Meichenbaum and Turk, 1987). It should be noted that it is common practice in the literature for the words adherence and compliance to be used interchangeably, with both being defined according to the Meichenbaum and Turk (1987) definition.
Rates of Adherence to Physiotherapy
Like other forms of health care, physiotherapy is not immune to the problem of poor adherence to treatment, but the extent of this problem remains unclear (Sluijs et al., 1998). Rates of adherence to rehabilitation programmes, of which physiotherapy is a part, have been based on attendance, and home-based patient behaviours. Percentages of attendance at scheduled physiotherapy sessions have been used as indicators of clinic-based adherence. Ludwig and Adams (1968) reported only 44% of patients completed their scheduled course of physiotherapy. A survey of outpatient physiotherapy clinics in Great Britain showed that between 5.8% and 10.68% of patients failed to present for their first appointments, and between 7.17% and 14.3% did not return for follow-up appointments (Vasey, 1990). Di Fabio et al. (1996) used attendance as the measure of adherence to physiotherapy for low back pain, with percentages of adherence of 85% for patients with herniated disc disease and 89% for those with mechanical low back pain.
Rates of adherence to the home-based components of physiotherapy programmes have been measured in five studies. A comparison of the effect of two different educational methods on adherence to exercises for acute and sub-acute low back pain showed participants given written and verbal information were more adherent (77%) to the exercises than those given verbal information only (38%) (Schneiders et al., 1998). In a New Zealand study adherence rates for exercises prescribed for patients with limb injuries were 74% for the number of exercise sessions and 70% for the number of repetitions performed at each session (Bassett and Petrie, 1999). A retrospective investigation of adherence to sport injury rehabilitation showed a 13% non-adherence rate to home exercises (Almekinders and Almekinders, 1994). Sluijs et al. (1993a) found 24% of patients were nonadherent, 35% were highly adherent and the remaining 41% of the sample were partially adherent to their home exercise programmes. Taylor and May (1996) classified participants as either fully adherent or non-adherent to the two main components of the rehabilitation. The percentage of participants who reported being nonadherent to the prescribed modalities (exercises, ice, heat, stretches) and the prescribed rest were 60% and 54% respectively, with the remaining participants being fully adherent.
Sluijs et al. (1993a) and Taylor and May (1996) only reported short-term adherence; that which occurs during the formal treatment programme. However, adherence to long-term exercise programmes which patients are expected to continue once the formal treatment programme has ceased, is notoriously poor (Ice, 1985; Sluijs et al., 1998). In a study of patient education in physiotherapy undertaken by Sluijs et al. (1993b) physiotherapists estimated long-term-adherence (up to one year following the clinic-based phase) at 20% in comparison to 70% for short-term adherence. Ice (1985) reported long-term therapeutic exercise programmes having dropout rates of between 30% and 50% within the first 12 months of their initiation, and between 45% and 80% within the first 48 months.
While it is apparent that adherence to physiotherapy programmes is less than desirable, it is difficult to draw conclusions about the exact extent of the problem because of the different ways in which the rates of adherence have been reported.
Measurement of Adherence
Rehabilitation programmes of which physiotherapy is part usually consist of a range of modalities all requiring different forms of behaviour. Thus any reliable evaluation of adherence needs to be multifaceted (Brewer, 1999). Patients' behaviours are complex and subject to change over time, with no guarantee that they will remain stable throughout a programme of treatment (Meichenbaum and Turk, 1987). To account for variability in patient behaviours and attitudes the assessment of adherence should be undertaken on a regular basis. Objective measures of adherence to clinic- and home-based physiotherapy programmes have been developed.
Assessment of clinic based adherence should consist of an indicator of clinic attendance and an evaluation of behaviours during the treatment session (Brewer, 1999). The percentage or ratio of attendance is a widely used index of adherence to the clinic-based component of rehabilitation (Brewer et al., 2000a; Byerly et al., 1994; Duda et al., 1989; Fisher et al., 1988; Udry, 1997). This index is calculated by dividing the number of sessions attended by the number of scheduled sessions (Brewer, 1999). However, clinic attendance does not measure patients' adherence behaviours during clinic-based physiotherapy session.
A number of observational methods have been devised to measure patients' adherence behaviours during the clinic-based component of the physiotherapy. Evans and Hardy (2002) used the physiotherapist's knowledge of the patient, clinical symptoms, rehabilitation progress and behavioural observations to give an adherence percentage. The individual contribution that each of these categories made to the overall adherence percentage was not clarified. Taylor and May (1996) also drew on the physiotherapist's observations of the patients as an indicator of adherence, with the adherence to each treatment modality being rated on a scale of none (0) to all (5). Neither Evans and Hardy (2002) nor Taylor and May (1996) provided any evidence of the reliability and validity of their physiotherapists' adherence measures.
An exercise proficiency scale was developed by (Codori et al., 1992) to measure adherence for patients with hand injuries. A three point scoring system was used to evaluate the following four dimensions of proficiency, 1) the adequacy of the plane of motion through which the joint was moved, 2) the number of repetitions performed, 3) the adequacy of the stabilisation provided by the uninvolved hand and 4) the adequacy and location of the force applied (passive exercises) or effort exerted (active exercises). Exercise proficiency measured in this manner was found to be significantly correlated to patients' self-reports of their home exercise adherence, with greater levels of adherence being associated with high proficiency scores. As there is no apparent evidence of this scale being tested with other injuries, its value as a global measure of clinic-based exercise behaviours remains uncertain.
The Sport Injury Rehabilitation Adherence Scale (SIRAS) was developed by Brewer et al. (1995) for measuring adherence behaviours during the clinic session. It is a three-item instrument that uses a five-point scale to assess the intensity with which patients complete their exercises, the extent to which they follow their practitioners' advice and instructions during the treatment, and the patients' receptiveness to changes made during the rehabilitation session (Figure 1). The reliability and validity of the SIRAS has been tested in a series of studies. Brewer et al. (2000b) evaluated the SIRAS, showing it to have high internal consistency, high test-retest reliability, moderate inter -rater reliability, and that the three items loaded onto a single factor, namely adherence. In addition a comparison of participants' SIRAS scores with their clinic attendance revealed a low but significant correlation, which was interpreted by Brewer and colleagues to be indicative of some overlap in the aspects of adherence measured by each. Further support for the SIRAS's ability to measure adherence to the clinic-based component of rehabilitation came from a study undertaken by Brewer et al. (2002) in which it was shown to have high interrater reliability, and construct validity. The SIRAS has successfully discriminated between adherent and nonadherent patients undergoing rehabilitation for low back pain (Kolt and McEvoy, 2003) and following knee surgery (Brewer et al., 2003; Brewer et al., 2000a).
[FIGURE 1 OMITTED]
The success of many physiotherapy programmes is reliant on patients undertaking prescribed activities at home. Patient diaries and self-report questionnaires are the most commonly reported methods of measuring adherence, with electronic devices used less frequently.
Diaries are used for recording each time exercises or other treatment activities are performed, the number of repetitions of each exercise, and the duration of application of ice or heat. Patients are expected to complete their diaries every time they undertake their home programme, and take them to each clinic appointment for checking and updating. A percentage of adherence to the prescribed home programme can be calculated from the patients' recordings. An advantage of dairies is that they can be an aid to adherence by acting as a cue to doing the activities. This advantage can be also viewed as a limitation, because a true measure of the patient's adherence is not being obtained (Brewer, 1999; Meichenbaum and Turk, 1987; Rand and Wise, 1994).
A variety of retrospective participant self-report measures have been designed to indicate the extent of adherence to home-based rehabilitation. Numerical scales that measure adherence from 'not at all' to 'fully' adherent have been used (Brewer et al., 2000b; Sluijs et al., 1993a; Taylor and May, 1996). As well, separate scales have been utilised for the participants to indicate their adherence to each of the different components of the home-based rehabilitation (Brewer et al., 2000a; Taylor and May, 1996) (Figure 2). The main limitation of retrospective self-reports is the possibility of inaccurate recall, and a bias toward an overestimation of doing the home-based activities (Myers and Midence, 1998). This weakness is nonetheless outweighed to some degree by their convenience and simplicity of use in comparison to diary recording (Meichenbaum and Turk, 1987).
[FIGURE 2 OMITTED]
Electronic devices such as electromyographic feedback, pedometers and stopwatches activated by video players are considered be objective measures of adherence. Electromyographic biofeedback connected to a portable computer has been used to count the number of times people do their exercises at home (Brewer, 1999). Pedometers, movement sensors, and accelerometers have also been utilised for assessing adherence to walking programmes (Vitolins et al., 2000). Stopwatches incorporated into video-players have been used by Hoelscher et al. (1984) to measure the time patients spend practising relaxation programmes at home. To ensure that the measurement of time was accurate the video-tapes were sealed into the players, and the time the player had been used was recorded at each clinic appointment. Hoelscher at al. (1984) also compared the times obtained from the stopwatches with patient self-reports of the time they spent on the home-based relaxation, with the latter being shown to be the higher estimation of adherence. In spite of electronic devices being considered accurate and able to provide an objective measure of adherence, they do have the potential to be unreliable as a result of mechanical wear and tear (Vitolins et al., 2000). Also these devices are expensive and therefore likely to be outside the realm of the average patient and physiotherapy clinic, and in the case of the video players there is no proof that patients do actually practice the relaxation while the video is being played.
In summary, it is evident that the measurement of adherence needs to reflect the behavioural demands of the physiotherapy programme that are placed on the patients. For most patients this will necessitate the inclusion of assessment of their clinic-based and home-based adherence behaviours.
Determinants of Adherence
If it is proven that patients are not adhering to their prescribed physiotherapy programme it is important to determine the reasons for this behaviour, so as appropriate steps can be taken to resolve the problem. Meichenbaum and Turk (1987) categorised the determinants of adherence as patients' personal characteristics, disease or injury variables, treatment variables and the interaction between the patient and the clinician.
Patients' Personal Characteristics
A range of personal characteristics has been associated with adherence, such as socio-demographic variables, adherence history, motivation and social support. The outcomes of studies investigating the role of socio-demographic variables on adherence have been conflicting. For example, middle-aged highly educated women were reported to be the least adherent to physiotherapy home exercise programmes (Sluijs et al., 1993a), whereas Hartigan et al. (2000) showed no relationship between adherence to low back pain exercise programmes and age, gender and educational attainment. The level of participants' sporting involvement (competitive or recreational) has also not been found to influence clinic attendance (Daly et al., 1995).
Previous adherence behaviours have proven to be strong predictors of current and future adherence to exercise programmes for osteoarthritis of the knee (Rejeski et al., 1997). Self-motivation has been consistently positively associated with adherence to sport injury rehabilitation programmes, of which physiotherapy is integral (Brewer, et al., 2000a; Duda et al., 1989; Fields et al., 1995; Fisher et al., 1988; Noyes et al., 1983). Social support that encourages patients to continue with their rehabilitation has been linked to high levels of adherence (Byerly et al., 1994; Duda et al., 1989).
Disease or Injury Variables
Disease related variables, such as chronic disorders and patients' perceptions of their symptoms have been shown to have a bearing on adherence. Two reasons for adherence to treatment programmes for chronic diseases or injuries being problematic have been identified. First during times of remission when the symptoms are absent patients lack relevant cues to continue with treatment (Sluijs and Knibbe, 1991). This may lead patients to falsely believe being asymptomatic is indicative of recovery, and therefore continuation of treatment, such as exercises, is not warranted. Second chronic disorders require long-term self-management or home programmes, and patients have difficulty integrating these into their normal daily activities. For prescribed activities to be of any benefit they need to become an automatic or habitual behaviour that are linked into routine daily activities (Sluijs and Knibbe, 1991).
Patients are more adherent to their rehabilitation when they perceive their injury as being serious (Taylor and May, 1996) and that they are vulnerable to further problems related to the injury as a consequence of not undertaking the prescribed rehabilitation activities (Brewer et al., 2003; Taylor and May, 1996). Debate surrounds the effect of patients' pain tolerance on their adherence to physiotherapy. Injured sports people with a high pain tolerance were significantly more likely to be adherent to the programme requirements than those with a poor tolerance (Byerly et al., 1994; Fields et al., 1995; Fisher et al., 1988). In contrast, other research has been unable to show a significant difference between the pain experiences of adherent and nonadherent physiotherapy patients (Sluijs et al., 1993a).
Adherence has been related to the timing of the treatment appointments, the clinic environment, the content of the treatment programme and patients' attitudes to the treatment. Patients are less likely to keep clinic appointments when these are scheduled at times they consider inconvenient (Fields et al., 1995; Fisher et al., 1988; Vasey, 1990), and if they are made too far in advance (Vasey, 1990). The clinic environment has been found to be of importance, with higher levels of adherence being reported among patients who feel the clinic has a comfortable atmosphere (Fields et al., 1995; Fisher et al., 1988; White et al., 1999).
Complex, intrusive, long-term programmes that require assistance from other people for their successful implementation have been associated with poor adherence rates (Flynn et al., 1995; Muszynski-Kwan et al., 1988). For other physiotherapy rehabilitation programmes that consist of exercises, their success is dependent upon patients taking an active role in their implementation and maintenance (Sluijs et al., 1998). Patients frequently find difficulty in maintaining exercise behaviours over the long-term, because of the problems encountered in making them part of their daily routines and overcoming the high number of perceived and real barriers to them (Sluijs and Knibbe, 1991). The most commonly perceived barriers to undertaking home exercise programmes are a lack of time to exercise, an inability to fit exercises into a daily routine and forgetting to exercise (Sluijs et al., 1993a). Low levels of adherence have also been linked to negative beliefs about the value of the exercises (Sluijs et al., 1993a). Notwithstanding, high levels of adherence have been related to beliefs about the rehabilitation being efficacious (Brewer et al., 2003; Duda et al, 1989; Taylor and May, 1996) and the patients' self-efficacy or perceptions about their ability to cope with the treatment requirements (Brewer et al., 2003; Taylor and May, 1996).
Communication between the patient and the clinician is considered to be central to establishing effective patient rapport (Pizzari et al., 2002; Purtilo and Haddad, 1996). Patients who had a positive relationship with their physiotherapists felt more inclined to attend their clinic appointments and complete their rehabilitation activities during these sessions (Pizzari et al., 2002). Adherence to physiotherapy exercise programmes was found to be significantly greater when physiotherapists gave patients positive feedback, asked them for feedback about their progress and treatment, regularly monitored their exercise performance and frequently motivated them to do their home exercises (Sluijs et al., 1993a). Conversely, physiotherapists can be responsible for poor levels of adherence if they give patients too much information and if that information is not specific to their needs and disorder (Sluijs, 1991).
Patients, too, may have problems in communication, and are not always truthful about their adherence to their home-based activities. For instance in a study of patient self-reports about their home exercises, in response to the physiotherapist's question "how about your exercises?" one patient stated "no problems", when in reality he was prevented from exercising because his job required him to drive for ten hours per day (Sluijs et al., 1998, p.372).
In brief, the determinants of adherence are a diverse range of physical, psychological and situational factors that are not likely to operate in isolation. For example, patients' beliefs about the efficacy of the treatment may stem from the information provided by the physiotherapist. If this information is presented in a precise and positive manner that patients understand then it is likely their beliefs about the treatment will be strengthened and their adherence enhanced.
Recommendations for Clinical Use
As the evidence points to approximately 65% of patients being likely to be nonadherent to some degree, physiotherapists should incorporate the evaluation of adherence into their routine patient assessments. Physiotherapists should not be confrontational or judgmental during such assessments as many patients are embarrassed by their lack of adherence. While discussion with patients and demonstration of the activities appears to be an adequate method of assessment, it may not be specific enough to detect the type and extent of the problem. It is recommended that physiotherapists select assessment methods that fit the demands of the programme, and are easy to use. Measurement of clinic-based adherence should include attendance and the patients' behaviours during the treatment session. The calculation of an attendance ratio will give an accurate indication of the extent to which patients have been attending their scheduled clinic appointments. The SIRAS (Brewer et al., 1995) is recommended for the evaluation of adherence behaviours throughout the treatment session and should be completed at the end of each clinic appointment. In addition to its proven psychometric properties, the SIRAS (Brewer et al., 1995) takes very little time to complete. Self-report scales are the simplest way of assessing adherence to the home-based programme. At each clinic appointment, patients record the extent to which they have adhered to the home-based modalities they were given for the time since their previous clinic-appointment.
The determinants of adherence are useful as a framework for identifying the underlying reasons for poor adherence. Patients may give many reasons for poor adherence, which seem quite nonsensical to physiotherapists, but to patients they are quite rational and valid. Physiotherapists should accept these reasons as well as being mindful of their possible negative influence on adherence. An awareness of the reasons for poor adherence enables physiotherapists to implement the appropriate strategies to rectify the problem.
Prevention of nonadherence is the ideal way of averting potential adherence problems. Extra time spent early on in a course of treatment discussing with patients their concerns about the treatment and their role in it, and outlining the treatment requirements is considered necessary for high levels of adherence (Meichenbaum and Turk, 1987). During a course of physiotherapy, the exercises and other activities are changed frequently and therefore to ensure adherence physiotherapists must make time to educate patients about the importance of these activities and what is required of them at each treatment session.
Poor patient adherence is a problem in physiotherapy, and because of the multifaceted nature of most rehabilitation programmes it can manifest as poor attendance and failure to follow the requirements of the clinic- and home-based components, and may vary over time. Assessment of adherence must allow for these complexities, yet be specific enough to capture the exact nature of the problems. Therefore, physiotherapists need to ensure the assessment methods are valid for the type of adherence being evaluated. For example, the SIRAS is a valid measure of patients' behaviours during a clinic-based treatment, not clinic attendance. Likewise, an accurate assessment of home-based adherence must target the different activities the patients have been expected to undertake. If adherence is proven to be less than desirable, an effective solution to the problem can only be sought when its underlying reasons have been identified. Alteration to physiotherapy treatment programmes should only then be considered when poor adherence cannot be remedied or if in spite of high levels of adherence the patient fails to recover as would be normally expected.
The content of this paper is based on aspects of the author's Ph.D. research. She wishes to acknowledge the expert guidance and support that her supervisor, Dr Harry Prapavessis, has provided in the preparation and writing of this paper and in her Ph.D. study. In addition the author wishes to thank Jackie Chiplin for advice she gave about the presentation of this paper.
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ADDRESS FOR CORRESPONDENCE
Department of Sport and Exercise Science, Tamaki Campus, The University of Auckland, Private Bag 92019, Auckland. 09)3737599 ext.86631 e-mail email@example.com
Sandra Frances Bassett
BA, MHSc (Hons),
Dip Phty (Otago)
Ph.D. Candidate, Department of Sport and Exercise Science,
The University of Auckland.
Figure 1: Sport Injury Rehabilitation Adherence Scale SPORT INJURY REHABILITATION ADHERENCE SCALE (SIRAS) To be completed by the physiotherapist at the end of each of the patient's treatment sessions. For each of the following circle the number that best indicates the patient's behaviour: 1. The intensity with which the patient completed the rehabilitation exercises during today's appointment minimum effort 1 2 3 4 5 maximum effort 2. During today's appointment, how frequently did the patient follow your instructions and advice? never 1 2 3 4 5 Always 3. How receptive was this patient to changes in the rehabilitation programme during today's appointment? very unreceptive 1 2 3 4 5 very receptive From: Brewer et al. (1995): A brief measure of adherence during sport injury rehabilitation sessions. Journal of Applied Sport Psychology 8(Suppl): S161.
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