Chronic osteoarthritis and adherence to exercise: a review of the literature

Risk factors for falls in older adults with lower extremity arthritis: a conceptual framework of current knowledge and future directions

PURPOSE

As the numbers of Canadians aged 65 years and over increases over the next 20 years, the prevalence of chronic conditions, including arthritis, will rise as will the number of falls. Although known fall-risk factors are associated with hip and knee osteoarthritis (OA), minimal research has evaluated fall and fracture risk and/or rates in this population. Thus, the purpose was to summarize research on fall and fracture risk in older adults with hip or knee OA and to develop a conceptual framework of fall-risk screening and assessment.

METHOD

The International Classification of Functioning, Disability and Health, clinical practice guidelines for fall-risk screening, and a selected literature review were used.

RESULTS

Gaps exist in our knowledge of fall and fracture risk for this population. Muscle performance, balance, and mobility impairments have been identified, but little is known about whether personal and environmental contextual factors impact fall and fracture risk. Physical activity may help to prevent falls, but non-adherence is a problem.

CONCLUSION

A need exists to assess fall risk in older adults with hip and knee OA. Promoting regular physical activity by focusing on disease- and activity-specific personal contextual factors may help direct treatment planning.

Perceived Benefits, Motives, and Barriers to Aqua-based Exercise Among Older Adults With and Without Osteoarthritis

This study aimed to (a) identify factors that motivate older adults to participate in aqua-based exercise; (b) identify potential barriers; and (c) compare perceptions between older adults with and without osteoarthritis (OA). Fifteen adults above 60 years of age participated in one of three focus groups during which they discussed perceived benefits, motives, and barriers to aqua exercise. Pain reduction was considered a major benefit among those with OA, improved health and fitness was a principal benefit for those without OA. All participants felt that the instructor could act as both a motivator and barrier; the most significant barrier was cold changing facilities in winter. With the exception of pain reduction, perceived benefits, motivators, and barriers to aqua-based exercise are similar among older adults with and without OA. A greater understanding of these factors may help us to facilitate older adults with OA to initiate and adhere to aqua-based exercise.

Factors associated with physical activity in patients with osteoarthritis of the hip or knee: a systematic review

OBJECTIVE

To give an overview of factors related to the level of physical activity in patients with hip or knee osteoarthritis (OA).

METHODS

An extensive systematic literature search was conducted in PubMed, CINAHL and Embase. Inclusion criteria were: studies on patients with a diagnosis of OA of hip and/or knee, studies describing factors related to physical activity (objective or subjective), full length articles that were published in Dutch, German or English language. Two reviewers independently assessed the methodological quality. A best-evidence synthesis was performed for factors which were investigated in two or more studies.

RESULTS

Eight studies were included, all with a cross-sectional design (five high quality and three low quality studies), resulting in, at most, limited evidence in the best-evidence synthesis. For patients with knee OA there is limited evidence that a lower level of physical function is associated with a lower level of physical activity. There is also limited evidence that depression is not associated with the level of physical activity. For patients with hip OA there is limited evidence that higher age, higher body mass index (BMI) and a low level of physical function is associated with a low level of physical activity.

CONCLUSION

A high age (hip OA), a high BMI (hip OA) and a low level of physical function (both hip and knee OA) are related to a low level of physical activity. However, the level of evidence was only limited. Before new strategies and interventions to increase physical activity in patients with OA can be developed, high quality longitudinal studies are needed to get more insight in the causality between factors and low levels of physical activity.

A review of the clinical evidence for exercise in osteoarthritis of the hip and knee

Osteoarthritis (OA) is a chronic joint disease with the hip and knee being commonly affected lower limb sites. Osteoarthritis causes pain, stiffness, swelling, joint instability and muscle weakness, all of which can lead to impaired physical function and reduced quality of life. This review of evidence provides recommendations for exercise prescription in those with hip or knee OA. A narrative review was performed. Conservative non-pharmacological strategies, particularly exercise, are recommended by all clinical guidelines for the management of OA and meta-analyses support these exercise recommendations. Aerobic, strengthening, aquatic and Tai chi exercise are beneficial for improving pain and function in people with OA with benefits seen across the range of disease severities. The optimal exercise dosage is yet to be determined and an individualized approach to exercise prescription is required based on an assessment of impairments, patient preference, co-morbidities and accessibility. Maximising adherence is a key element dictating success of exercise therapy. This can be enhanced by the use of supervised exercise sessions (possibly in class format) in the initial exercise period followed by home exercises. Bringing patients back for intermittent consultations with the exercise practitioner, or attendance at "refresher" group exercise classes may also assist long-term adherence and improved patient outcomes. Few studies have evaluated the effects of exercise on structural disease progression and there is currently no evidence to show that exercise can be disease modifying. Exercise plays an important role in managing symptoms in those with hip and knee OA.

Exercise adherence improving long-term patient outcome in patients with osteoarthritis of the hip and/or knee

OBJECTIVE

To determine the effect of patient exercise adherence within the prescribed physical therapy treatment period and after physical therapy discharge on patient outcomes of pain, physical function, and patient self-perceived effect in individuals with osteoarthritis (OA) of the hip and/or knee.

METHODS

We performed a prospective observational followup study in which 150 patients with OA of the hip and/or knee receiving exercise therapy were followed for 60 months. Data were obtained from a randomized controlled trial, with assessments at baseline and 3, 15, and 60 months of followup. The association between exercise adherence and patient outcomes of pain, physical function, and self-perceived effect was examined using generalized estimating equations analyses.

RESULTS

Adherence to recommended home exercises and being more physically active were significantly associated with better treatment outcomes of pain, self-reported physical function, physical performance, and self-perceived effect. The association between adherence and outcome was consistent over time. Adherence to home activities was only associated with better self-perceived effect.

CONCLUSION

Better adherence to recommended home exercises as well as being more physically active improves the long-term effectiveness of exercise therapy in patients with OA of the hip and/or knee. Both within and after the treatment period, better adherence is associated with better patient outcomes of pain, physical function, and self-perceived effect. Since exercise adherence declines over time, future research should focus on how exercise behavior can be stimulated and maintained in the long term.

Behavioural graded activity results in better exercise adherence and more physical activity than usual care in people with osteoarthritis: a cluster-randomised trial

QUESTION

Does behavioural graded activity result in better exercise adherence and more physical activity than usual care in people with osteoarthritis of the hip or knee?

DESIGN

Analysis of secondary outcomes of a cluster-randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

Two hundred patients with hip and/or knee osteoarthritis.

INTERVENTION

Experimental group received 18 sessions of behavioural graded activity over 12 weeks and up to 7 booster sessions over the next year. The control group received 18 sessions of usual care over 12 weeks according to the Dutch physiotherapy guideline.

OUTCOME MEASURES

Exercise adherence was measured using a questionnaire and physical activity was measured using the SQUASH questionnaire at baseline, 13, and 65 weeks.

RESULTS

Adherence to recommended exercises was significantly higher in the experimental group than in the control group at 13 weeks (OR 4.3, 95% CI 2.1 to 9.0) and at 65 weeks (OR 3.0, 95% CI 1.5 to 6.0). Significantly more of the experimental than the control group met the recommendations for physical activity at 13 weeks (OR 5.3, 95% CI 1.9 to 14.8) and at 65 weeks (OR 2.9, 95% CI 1.2 to 6.7).

CONCLUSION

Behavioural graded activity results in better exercise adherence and more physical activity than usual care in people with osteoarthritis of the hip or knee, both in the short- and long-term.

TRIAL REGISTRATION

NCT00522106.

Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized controlled trial comparing two different physical therapy interventions

OBJECTIVE

To determine if behavioral graded activity (BGA) results in better long-term effectiveness (5 years after inclusion) than usual exercise therapy (UC; usual care) in patients with osteoarthritis (OA) of the hip or knee.

METHOD

Long-term follow-up study of a single blind cluster randomized trial comparing BGA and UC. One hundred and forty-nine patients out of the 200 included were followed until 60 months' follow-up. Primary outcome measures were pain, physical function, and patient global assessment. Furthermore, patient-oriented physical function, physical performance, health care utilization and the number of joint replacement surgeries were assessed. Assessments took place at 3, 9, 15 and 60 months' follow-up. Data were analyzed according to intent-to-treat principle.

RESULTS

Both treatments showed beneficial within-groups effects in the long-term. In patients with knee OA no differences between treatments were found on the short-, mid-long and long-term. In patients with hip OA significant differences in favor of BGA were found at 3 months' (pain and physical performance) and 9 months' follow-up (pain, physical function, patients global assessment and patient-oriented physical function). Furthermore, UC resulted in patients with hip OA in more joint replacement surgeries compared to BGA (hazard ratio [HR], 2.87; 95% confidence interval [CI], 1.1; 7.3).

CONCLUSION

No differences between treatment groups were found in the long-term on the primary outcome measures. Although more research is needed to confirm the study findings, the results indicate that BGA reduces the risk for joint replacement surgeries compared to UC in patients with hip OA, which probably can be explained by better outcome in favor of BGA in the short- and mid-long-term.

Facilitators and barriers to exercising among people with osteoarthritis: a phenomenological study

BACKGROUND

Evidence indicates that regular exercise improves the well-being of individuals with osteoarthritis (OA). However, these individuals seem to exercise less frequently than the general population and seem to have limited adherence to exercising.

OBJECTIVES

The purposes of this study were: (1) to increase knowledge and understanding of the experience of exercising among individuals with OA and (2) to determine what they perceive as facilitators and barriers to exercising.

DESIGN AND METHOD

This study used a qualitative method, based on the Vancouver School of doing phenomenology, involving purposive sampling of 12 individuals and 16 interviews. The participants, 9 women and 3 men, were 50 to 82 years of age.

RESULTS

Extended information on exercise behavior among people with OA is presented in a model in which internal and external facilitators and barriers to exercising are delineated. Based on this model, a checklist is proposed for physical therapists' assessment of these factors. Internal factors include individual attributes and personal experience of exercising, whereas external factors include the social and physical environment. The participants expressed how each of these internal and external factors could act both as a facilitator and a barrier to exercise participation and the pattern of exercising; for example, the presence of pain was an important aspect concerning internal barriers to exercising, whereas the hope of less pain was one of the main facilitators.

CONCLUSIONS

Increased knowledge and understanding of the factors influencing exercise behavior in people with OA can help physical therapists and other health care professionals support them in initiating and maintaining a healthy exercise routine and, consequently, achieving a better quality of life.

Efficacy of a progressive walking program and glucosamine sulphate supplementation on osteoarthritic symptoms of the hip and knee: a feasibility trial

Introduction

Management of osteoarthritis (OA) includes the use of non-pharmacological and pharmacological therapies. Although walking is commonly recommended for reducing pain and increasing physical function in people with OA, glucosamine sulphate has also been used to alleviate pain and slow the progression of OA. This study evaluated the effects of a progressive walking program and glucosamine sulphate intake on OA symptoms and physical activity participation in people with mild to moderate hip or knee OA.

Methods

Thirty-six low active participants (aged 42 to 73 years) were provided with 1500 mg glucosamine sulphate per day for 6 weeks, after which they began a 12-week progressive walking program, while continuing to take glucosamine. They were randomized to walk 3 or 5 days per week and given a pedometer to monitor step counts. For both groups, step level of walking was gradually increased to 3000 steps/day during the first 6 weeks of walking, and to 6000 steps/day for the next 6 weeks. Primary outcomes included physical activity levels, physical function (self-paced step test), and the WOMAC Osteoarthritis Index for pain, stiffness and physical function. Assessments were conducted at baseline and at 6-, 12-, 18-, and 24-week follow-ups. The Mann Whitney Test was used to examine differences in outcome measures between groups at each assessment, and the Wilcoxon Signed Ranks Test was used to examine differences in outcome measures between assessments.

Results

During the first 6 weeks of the study (glucosamine supplementation only), physical activity levels, physical function, and total WOMAC scores improved (P < 0.05). Between the start of the walking program (Week 6) and the final follow-up (Week 24), further improvements were seen in these outcomes (P < 0.05) although most improvements were seen between Weeks 6 and 12. No significant differences were found between walking groups.

Conclusions

In people with hip or knee OA, walking a minimum of 3000 steps (~30 minutes), at least 3 days/week, in combination with glucosamine sulphate, may reduce OA symptoms. A more robust study with a larger sample is needed to support these preliminary findings.

Trial Registration

Australian Clinical Trials Registry ACTRN012607000159459.

Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults

BACKGROUND

Chronic musculoskeletal pain (CMP) is a major health problem, accounting for approximately one-quarter of general practice (GP) consultations in the United Kingdom (UK). Exercise and physical activity is beneficial for the most common types of CMP, such as back and knee pain. However, poor adherence to exercise and physical activity may limit long-term effectiveness.

OBJECTIVES

To assess the effects of interventions to improve adherence to exercise and physical activity for people with chronic musculoskeletal pain.

SEARCH STRATEGY

We searched the trials registers of relevant Cochrane Review Groups. In addition, we searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, Science Citation Index and Social Science Citation Index and reference lists of articles to October 2007. We consulted experts for unpublished trials.

SELECTION CRITERIA

Randomised or quasi-randomised trials evaluating interventions that aimed to improve adherence to exercise and physical activity in adults with pain for three months and over in the axial skeleton or large peripheral joints.

DATA COLLECTION AND ANALYSIS

Two of the four authors independently assessed the quality of each included trial and extracted data. We contacted study authors for missing information.

MAIN RESULTS

We included 42 trials with 8243 participants, mainly with osteoarthritis and spinal pain. Methods used for improving and measuring adherence in the included trials were inconsistent. Two of the 17 trials that compared different types of exercise showed positive effects, suggesting that the type of exercise is not an important factor in improving exercise adherence. Six trials studied different methods of delivering exercise, such as supervising exercise sessions, refresher sessions and audio or videotapes of the exercises to take home. Of these, five trials found interventions improved exercise adherence. Four trials evaluated specific interventions targeting exercise adherence; three of these showed a positive effect on exercise adherence. In eight trials studying self-management programmes, six improved adherence measures. One trial found graded activity was more effective than usual care for improving exercise adherence. Cognitive behavioural therapy was effective in a trial in people with whiplash-associated disorder, but not in trials of people with other CMP. In the trials that showed a positive effect on adherence, association between clinical outcomes and exercise adherence was conflicting.

AUTHORS' CONCLUSIONS

Interventions such as supervised or individualised exercise therapy and self-management techniques may enhance exercise adherence. However, high-quality, randomised trials with long-term follow up that explicitly address adherence to exercises and physical activity are needed. A standard validated measure of exercise adherence should be used consistently in future studies.

Building motivation and sustainability into the prescription and recommendations for physical activity and exercise therapy: the evidence

Client adherence to exercises prescribed by a physical therapist is very important to successful treatment outcomes. Unfortunately, many clients struggle with adherence and thus efficient and effective motivational interventions are desirable. The purpose of this article was to review the available evidence for: 1) the modifiable factors associated with adherence to physical therapy recommended exercise and 2) the efficacy of exercise intervention efforts to make conclusions and suggestions toward practice. Articles were limited to English peer-reviewed journals and published from 1993 to 2008. Major findings from 13 studies were summarized based on common subtopics of: outcome expectations, self-efficacy expectations, cognitive-behavioural and educational interventions, and intervention medium. The review provided evidence for the importance of self-efficacy in exercise adherence to physical therapy, but it showed that current cognitive-behavioural interventions have had limited effectiveness. It was recommended that future research broaden the scope of predictor variables with social ecological designs, increase the length of prospective follow-up in assessments, include larger and more diverse samples, and focus on innovative aesthetic and affective-based intervention strategies.

Therapeutic aquatic exercise in the treatment of low back pain: a systematic review

Objective: To examine the effectiveness of therapeutic aquatic exercise in the treatment of low back pain.

Design: A systematic review.

Methods: A search was performed of PEDro, CINAHL (ovid), PUBMED, Cochrane Controlled Trials Register and SPORTDiscus databases to identify relevant studies published between 1990 and 2007. Population: Adults suffering from low back pain. Intervention: All types of therapeutic aquatic exercise. Comparison: All clinical trials using a control group. Outcomes: Oswestry Disability Index, McGill Pain Questionnaire, subjective assessment scale for pain (e.g. visual analogue scale) and number of work days lost as a direct result of low back pain. Methodological quality was assessed using the PEDro scale and the SIGN 50 assessment forms.

Results: Thirty-seven trials were found and seven were accepted into the review. Therapeutic aquatic exercise appeared to have a beneficial effect, however, no better than other interventions. Methodological quality was considered low in all included studies. The heterogeneity among studies, in numbers of subjects, symptoms durations, interventions and reporting of outcomes, precluded any extensive meta-analysis of the results.

Conclusion: There was sufficient evidence to suggest that therapeutic aquatic exercise is potentially beneficial to patients suffering from chronic low back pain and pregnancy-related low back pain. There is further need for high-quality trials to substantiate the use of therapeutic aquatic exercise in a clinical setting.

Muscle and exercise in the prevention and management of knee osteoarthritis: an internal medicine specialist's guide

This article outlines the influence of muscle activity on knee-joint loading, describes the deficits in muscle function observed in people with knee osteoarthritis, and summarizes available evidence pertaining to the role of muscle in the development and progression of knee osteoarthritis. The article focuses on whether muscle deficits can be modified in knee osteoarthritis and whether improvements in muscle function lead to improved symptoms and joint structure. This article concludes with a discussion of exercise prescription for muscle rehabilitation in knee osteoarthritis.

Physical therapists' use of therapeutic exercise for patients with clinical knee osteoarthritis in the United kingdom: in line with current recommendations?

BACKGROUND AND PURPOSE

Physical therapists have an important role in the management of clinical knee osteoarthritis (OA) through designing and supervising exercise programs. This study explored whether their current use of therapeutic exercise for patients with this condition is in line with recent recommendations.

SUBJECTS AND METHODS

A cross-sectional survey was conducted with a random sample of chartered (licensed) physical therapists (N=2,000) practicing in the United Kingdom. This survey included a vignette describing a patient with clinical knee OA as well as clinical management questions relating to the respondents' use of therapeutic exercise.

RESULTS

The questionnaire response rate was 58% (n=1,152), with 538 respondents stating they had treated a patient with clinical knee OA in the preceding 6 months. In line with recent recommendations, 99% of the physical therapists stated they would use therapeutic exercise for this patient population, although strengthening exercises were favored over aerobic exercises. Although nearly all physical therapists would monitor exercise adherence, only 12% would use an exercise diary. Seventy-six percent of physical therapists would provide up to 5 treatment sessions, and only 34% would offer physical therapy follow-up after discharge.

DISCUSSION AND CONCLUSION

The measure of physical therapists' current clinical practice was self-reported clinical behavior on the basis of a vignette. Although this is a valid measure of clinical behavior, in practice, physical therapists may use therapeutic exercise differently. There are disparities between physical therapists' current use of therapeutic exercise for clinical knee OA and recent recommendations. Identifying potential ways to overcome these disparities is an important step toward optimizing the outcome from therapeutic exercise for patients with clinical knee OA.

Effectiveness of two Arthritis Foundation programs: Walk With Ease, and YOU Can Break the Pain Cycle

OBJECTIVE

To evaluate the effectiveness of two Arthritis Foundation programs: Walk With Ease (WWE) and YOU Can Break The Pain Cycle (PC).

DESIGN

Quasi-experimental, repeated measures design. Retested at six weeks and four months.

SETTING

Community based intervention.

PARTICIPANTS

Volunteer sample of 163 adults with arthritis recruited through mailings, newspapers, and flyers.

INTERVENTIONS

Subjects participated in a 90 minute seminar (PC, Group A), a six-week walking program (WWE, Group B), or both programs (Group C).

MAIN OUTCOME MEASURES

Survey assessment of arthritis knowledge, general health, self-management activities, confidence, physical abilities, depression, health distress, and how arthritis affects their life. A Squat Test, a Six Minute Walk test, and a Timed Functional Walk Test were also administered.

RESULTS

Subjects in Group B were more confident, less depressed, had less health distress, and less pain than subjects in Group A. Scores of Group C were between Group A and B scores. Differences in groups over time indicated that the WWE resulted in increased confidence, physical abilities, time spent in self-management activities and decreased pain and fatigue. All groups increased in walking endurance at six weeks, and increased in health distress at four months.

CONCLUSION

Subjects in different programs differed on impact of arthritis. These programs provide effective arthritis management opportunities.

Physical therapy interventions for patients with osteoarthritis of the knee: an overview of systematic reviews

Patients with osteoarthritis of the knee are commonly treated by physical therapists. Practice should be informed by updated evidence from systematic reviews. The purpose of this article is to summarize the evidence from systematic reviews on the effectiveness of physical therapy for patients with knee osteoarthritis. Systematic reviews published between 2000 and 2007 were identified by a comprehensive literature search. We graded the quality of evidence across reviews for each comparison and outcome. Twenty-three systematic reviews on physical therapy interventions for patients with knee osteoarthritis were included. There is high-quality evidence that exercise and weight reduction reduce pain and improve physical function in patients with osteoarthritis of the knee. There is moderate-quality evidence that acupuncture, transcutaneous electrical nerve stimulation, and low-level laser therapy reduce pain and that psychoeducational interventions improve psychological outcomes. For other interventions and outcomes, the quality of evidence is low or there is no evidence from systematic reviews.

Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review

OBJECTIVE

To determine the long-term effectiveness (>/=6 months after treatment) of exercise therapy on pain, physical function, and patient global assessment of effectiveness in patients with osteoarthritis (OA) of the hip and/or knee.

METHODS

We conducted an extensive literature search in PubMed, EMBase, CINAHL, SciSearch, PEDro, and the Cochrane Central Register of Controlled Trials. Both randomized clinical trials and controlled clinical trials on the long-term effectiveness of exercise therapy were included. The followup assessments were at least 6 months after treatment ended. Methodologic quality was independently assessed by 2 reviewers. Effect estimates were calculated and a best evidence synthesis was performed based on design, methodologic quality, and statistical significance of findings.

RESULTS

Five high-quality and 6 low-quality randomized clinical trials were included. Strong evidence was found for no long-term effectiveness on pain and self-reported physical function, moderate evidence for long-term effectiveness on patient global assessment of effectiveness, and conflicting evidence for observed physical function. For exercise programs with additional booster sessions, moderate evidence was found for long-term effectiveness on pain, self-reported physical function, and observed physical function.

CONCLUSION

The positive posttreatment effects of exercise therapy on pain and physical function in patients with OA of the hip and/or knee are not sustained in the long term. Long-term effectiveness was only found for patient global assessment of effectiveness. However, additional booster sessions after the treatment period positively influenced maintenance of beneficial posttreatment effects on pain and physical function in the long term.

Behavioral Medicine Review: The Dialectic of Tradition and Progress in Osteoarthritis Management

In his state of the art review, Katz provided an evidence-based perspective on nonpharmacologic approaches to osteoarthritis. His overview prompts discussion of the tradition-progress dialectic that has punctuated this area as exemplified, on one hand, by continuing tendencies to privilege biomedical over biopsychosocial conceptualizations and persisting barriers to the widespread implementation of nonpharmacologic, best-evidence treatments in primary care. On the other hand, the field has been sparked by considerable innovation, including the bursting of traditional treatment boundaries, an expanding range of intervention strategies, and the emergence of promising trends that may unleash further advances in patient care.

Osteoarthritis and the impact on quality of life health indicators

The purpose of this study was to compare quality of life health identifiers in patients with and without osteoarthritis (OA) while controlling for the potentially confounding variables of gender, age, race, education, and income. Data were obtained for comparison from the Behavioral Risk Factor Surveillance System (BRFSS) database. Patients with and without OA were analyzed for differences in exercise and activity level, report of physical and mental health, and joint-related symptoms. Over 37,000 individuals were included in the analysis, 6,172 of the participants reported a diagnosis of OA. Participants with a report of OA were more likely to identify problems in all categories except report of mental health. When the potentially confounding variables were controlled, individuals with OA were more likely to report mental health problems. These findings suggest that individuals with OA are more likely to report lower levels of quality of life even while controlling confounding variables.

Active involvement and long-term goals influence long-term adherence to behavioural graded activity in patients with osteoarthritis: a qualitative study

QUESTION

Why do some patients who have received a behavioural graded activity program successfully integrate the activities into their daily lives and others do not?

DESIGN

Qualitative study.

PARTICIPANTS

12 patients were selected according to the model of deliberate sampling for heterogeneity, based on their success with the intervention as assessed on the Patient Global Assessment.

INTERVENTION

Behavioural graded activity.

OUTCOME MEASURES

Data from 12 interviews were coded and analysed using the methods developed in grounded theory. The interviews covered three main themes: aspects related to the content of behavioural graded activity, aspects related to experience with the physiotherapist, and aspects related to characteristics of the participant.

RESULTS

Interview responses suggest that two factors influence long-term adherence to exercise and activity.First, initial long-term goals rather than short-term goals seem to relate to greater adherence to performing activities in the long term. Second, active involvement by participants in the intervention process seems to relate to greater adherence to performing activities in the long term.

CONCLUSION

Although involvement of patients in the intervention process is already part of behavioural graded activity, it would be beneficial to emphasise the importance of active involvement by patients right from the start of the intervention. Furthermore, to increase the success of behavioural graded activity, physiotherapists should gain a clear understanding of the patient's initial motives in undergoing intervention.