Predictors of compliance with short-term treatment among patients with back pain

Factors Associated With Compliance With Self-Management Home Therapies for Spine Pain: A Survey of Participants Attending a Chiropractic Teaching Clinic in South Africa

Objective

The purpose of this study was to determine factors that affect compliance with various prescribed home therapies based on reported feedback from participants with spine pain.

Methods

This was a descriptive, quantitative, cross-sectional survey. A purposive sampling method was used to recruit 121 participants with neck and back pain attending the Durban University of Technology Chiropractic Day Clinic located in KwaZulu-Natal, South Africa. Data were collected using a self-administered questionnaire. Descriptive statistics, including frequencies and percentages, were used to summarize the data, and odds ratios (ORs) were calculated.

Results

Most participants presented with chronic pain, reporting an average severity of 6 out of 10 and little disability from the pain. Home therapy included stretches (92.2%), heat therapy (49.1%), and ice therapy (38.8%). Almost two-thirds (62.1%) of participants reported being fully compliant with the prescribed home therapy, while 32.8% reported partial compliance. The main factors that potentially affected compliance were laziness and forgetfulness. Participants who reported having depression were less compliant (OR, 0.181), while those with chronic pain were more compliant (OR, 3.74). Those who believed that home therapy would alleviate their pain were also more compliant (OR, 3.83).

Conclusion

The study found that a majority of participants with spine pain were compliant with prescribed chiropractic home treatment. Key factors that potentially influenced compliance were identified.

Patient Compliance With Physical Therapy Following Orthopedic Surgery and Its Outcomes

BACKGROUND AND OBJECTIVES

Patient compliance is a major concern for the efficacy of physiotherapy amongst those that undergo orthopedic surgery. The substantial number of people who are non-compliant makes this an imperative issue to address. Our objectives were to quantify the percentage of patient compliance for physiotherapy after their surgery, to measure the association between compliance and the status of health, mobility, and pain, and to identify the causes of non-compliance.

METHODS

A cross-sectional study was conducted on post-orthopedic surgery patients attending physical therapy sessions at King Khalid University Hospital in Riyadh, Kingdom of Saudi Arabia, over a one-year period. The sample size of 359 was calculated and selected using simple random sampling. Our questionnaire was developed by adopting questions from two previously validated studies.

RESULTS

The majority of the participants (n=194; 54%) were male. One hundred and ninety-three (53.8%) participants had a diploma or higher. The age group 18-35 was found to be significantly associated with skipping physiotherapy sessions when they started to feel well (P= 0.016) and skipping due to other responsibilities (P=0.002). Single people skip physiotherapy when they start to feel well (P=0.023), due to other responsibilities (P=0.028), and due to poor timing (P=0.049). Self-reported compliance to physical therapy after surgery was 231 (64.3%). Patient status showed overall improvement.

CONCLUSION

There is a significant percentage of non-compliance and the patient's age, gender, marital status, and level of education play a role in the causes of non-compliance. In addition, the patient's status (health, pain, and mobility) is better in those who are compliant than in those who are not.

Harnessing People's Lived Experience to Strengthen Health Systems and Support Equitable Musculoskeletal Health Care

BACKGROUND: Despite the rising burden of musculoskeletal (MSK) problems (MSK conditions, MSK pain, and MSK injury and trauma) in most countries, actions to improve (strengthen) systems for supporting MSK health are often low on the priority list, relative to other noncommunicable diseases. Delivering effective, person-centered and equitable MSK health care requires strengthening systems for health, for example, through policy, financing, service delivery, and workforce initiatives. A critical, but often overlooked component is genuine integration of lived experience perspectives to cocreate care and systems that are responsive to people's needs and contexts. CLINICAL QUESTION: How can cocreation approaches support effective, person-centered and equitable MSK health care? What principles can stakeholders adopt to build responsive health systems? KEY RESULTS: Lived experience perspectives are not systematically integrated in initiatives to strengthen health systems. However, such integration is critical to creating equitable and person-centered health systems that provide care and support healthy populations. Cocreation principles and frameworks can guide processes to strengthen health systems, which must include historically marginalized groups and consider social and environmental contexts as they relate to health. CLINICAL APPLICATION: Clinicians, educators, and policy-makers play a critical role in creating equitable health systems and environments, and driving system reform with people who have lived experience. Genuine cocreation approaches capture diverse economic development (in particular, low-resource settings where health inequities are more prevalent), span the life course and diagnostic categories, are appropriate and/or adapted for the context and setting, and reflect evolving standards and opportunities for MSK health. J Orthop Sports Phys Ther 2023;53(4):1-10. Epub: 12 December 2022. doi:10.2519/jospt.2022.11427.

The AERO study: A feasibility randomised controlled trial of individually tailored exercise adherence strategies based on a brief behavioural assessment for older people with musculoskeletal conditions

INTRODUCTION

Exercise is a widely used treatment modality for older people with musculoskeletal conditions. The effectiveness of exercise programmes is limited by adherence. The aims of this study were to examine the acceptability and feasibility of the AERO intervention in facilitating exercise adherence in older people with musculoskeletal conditions, and to inform the design of a future randomised controlled trial.

METHODS

A two arm feasibility randomised controlled trial with an embedded qualitative study conducted at one orthopaedic hospital in the South of England. Older adults referred to physiotherapy with musculoskeletal conditions were randomised to receive either usual care consisting of standard physiotherapy only, or the AERO intervention, consisting of usual care with the addition of tailored exercise adherence approaches based on a brief behavioural assessment. Feasibility outcomes included recruitment, randomisation, retention, acceptability, and fidelity to trial protocol. Secondary outcomes included exercise adherence, physical activity, and behavioural regulation.

RESULTS

48 participants were recruited to the study with 27 randomised to usual care and 21 to AERO and usual care. On the basis of recruitment, retention, the acceptability to participants and physiotherapists and fidelity, the AERO intervention was determined to be feasible.

CONCLUSION

The AERO intervention in which participants received tailored adherence strategies based on a behavioural assessment plus standard physiotherapy is feasible and acceptable. It is now ready to be tested in an adequately powered randomised controlled trial.

CONTRIBUTION OF THE PAPER

CLINICAL TRIAL REGISTRATION NUMBER: This study was registered at clinicaltrials.gov REF: NCT03643432.

Usability of a wearable device for home-based upper limb telerehabilitation in persons with stroke: A mixed-methods study

Background

The use of wearable technology offers a promising home-based self-directed option for upper limb training. Although product usability is a crucial aspect of users' acceptance of a wearable device, usability studies in wearable devices are rare, with most studies focusing primarily on clinical validity.

Objective

This study aimed to explore the usability of a wristwatch device called "Smart reminder" for home-based upper limb telerehabilitation for persons with stroke.

Methods

Eleven stroke participants used the proposed wristwatch for at least two weeks and underwent a home-based telerehabilitation program. A mixed-methods design was used to explore the usability of the wristwatch. Quantitative data were collected through the System Usability Scale (SUS) questionnaire, and the participants' rate of therapy compliance (gathered from the device) was reported descriptively. In addition, qualitative data were collected through semi-structured interviews with the participants and were analyzed using thematic analysis.

Results

The results demonstrated that the usability of the proposed wristwatch and telerehabilitation system was rated highly by the participants, with a high SUS mean score of 84.3 (12.3) and high therapy compliance rate (mean  =  91%). Qualitatively, all participants reported positive experiences with the wristwatch and indicated keenness to use it again. Participants reported physical improvements and felt motivated to exercise after using the wristwatch. They found the device easy and convenient and appreciated the remote monitoring function. Meanwhile, they highlighted critical considerations for the design of the device and program, including technical support, a wearable design of the device, graded exercise content according to ability, and flexibility in exercise schedules. Finally, they suggested that an interim review with the therapist on their progress might help them continue using the wristwatch.

Conclusions

This study's results supported the proposed wearable device's usability and showed strong acceptance by the participants for using it as a home-based upper limb telerehabilitation intervention.

Factors impacting adherence to an exercise-based physical therapy program for individuals with low back pain

Background/Objective

Exercise-based rehabilitation is a conservative management approach for individuals with low back pain. However, adherence rates for conservative management are often low and the reasons for this are not well described. The objective of this study was to evaluate predictors of adherence and patient-reported reasons for non-adherence after ceasing a supervised exercise-based rehabilitation program in individuals with low back pain.

Design

Retrospective observational study.

Methods

Data was retrospectively analyzed from 5 rehabilitation clinics utilizing a standardized exercise-based rehabilitation program. Baseline demographics, diagnosis and symptom specific features, visit number, and discontinuation profiles were quantified for 2,243 patients who underwent the program.

Results

Forty-three percent (43%) of participants were adherent to the program, with the majority (31.7%) discontinuing treatment prior to completion due to logistic and accessibility issues. Another 13.2% discontinued prior to the prescribed duration due to clinically significant improvements in pain and/or disability without formal discharge evaluation, whereas 8.3% did not continue due to lack of improvement. Finally, 6.0% were discharged for related and unrelated medical reasons including surgery. Individuals diagnosed with disc pathology were most likely to be adherent to the program.

Limitations

This study was a retrospective chart review with missing data for some variables. Future studies with a prospective design would increase quality of evidence.

Conclusions

The majority of individuals prescribed an in-clinic exercise-based rehabilitation program are non-adherent. Patient diagnosis was the most important predictor of adherence. For those who were not adherent, important barriers include personal issues, insufficient insurance authorization and lack of geographic accessibility.

Extended effects of a wearable sensory prosthesis on gait, balance function and falls after 26 weeks of use in persons with peripheral neuropathy and high fall risk—The walk2Wellness trial

Background

We recently reported that individuals with impaired plantar sensation and high fall risk due to sensory peripheral neuropathy (PN) improved gait and balance function following 10 weeks of use of Walkasins^®, a wearable lower limb sensory prosthesis that provides directional specific mechanical tactile stimuli related to plantar pressure measurements during standing and walking (RxFunction Inc., Eden Prairie, MN, United States). Here, we report 26-week outcomes and compare pre- and in-study fall rates. We expected improvements in outcomes and reduced fall rates reported after 10 weeks of use to be sustained.

Materials and methods

Participants had clinically diagnosed PN with impaired plantar sensation, high fall risk (Functional Gait Assessment, FGA score < 23) and ability to sense tactile stimuli above the ankle at the location of the device. Additional outcomes included 10 m Gait Speed, Timed Up and Go (TUG), Four-Stage Balance Test, and self-reported outcomes, including Activities-Specific Balance Confidence scale and Vestibular Disorders Activities of Daily Living Scale. Participants tracked falls using a calendar.

Results

We assessed falls and self-reported outcomes from 44 individuals after 26 weeks of device use; 30 of them conducted in-person testing of clinical outcomes. Overall, improvements in clinical outcomes seen at 10 weeks of use remained sustained at 26 weeks with statistically significant increases compared to baseline seen in FGA scores (from 15.0 to 19.2), self-selected gait speed (from 0.89 to 0.97 m/s), and 4-Stage Balance Test (from 25.6 to 28.4 s), indicating a decrease in fall risk. Non-significant improvements were observed in TUG and fast gait speed. Overall, 39 falls were reported; 31 of them did not require medical treatment and four caused severe injury. Participants who reported falls over 6 months prior to the study had a 43% decrease in fall rate during the study as compared to self-report 6-month pre-study (11.8 vs. 6.7 falls/1000 patient days, respectively, p < 0.004), similar to the 46% decrease reported after 10 weeks of use.

Conclusion

A wearable sensory prosthesis can improve outcomes of gait and balance function and substantially decreases incidence of falls during long-term use. The sustained long-term benefits in clinical outcomes reported here lessen the likelihood that improvements are placebo effects.

Clinical trial registration

ClinicalTrials.gov, identifier #NCT03538756.

Can Physical Therapy Deliver Clinically Meaningful Improvements in Pain and Function through a Mobile App?: An Observational Retrospective Study

Objective

To examine the effect of digital physical therapy (PT) delivered by mobile application (app) on reducing pain and improving function for people with a variety of musculoskeletal conditions.

Design

An observational, longitudinal, retrospective study using survey data collected pre- and postdigital PT to estimate multilevel models with random intercepts for patient episodes.

Setting

Privately insured employees participating in app-based PT as an employer health care benefit.

Participants

The study sample included 814 participants (N=814) 18 years or older who completed their digital PT program with reported final clinical outcomes between February 2019 (program launch) through December 2020. Mean age of the sample at baseline was 40.9±11.89 years, 47.5% were female, 21% sought care for lower back pain, 16% for shoulders, 15% for knees, and 13% for neck.

Interventions

Digital PT consisted of a synchronous video evaluation with a physical therapist followed by a course of PT delivered through a mobile app.

Main Outcome Measures

Pain was measured by the visual analog scale from 0 “no pain” to 10 “worst pain imaginable” and physical function by the Patient-Specific Functional Scale on a scale from 0 “completely unable to perform” to 10 “able to perform normally.”

Results

After controlling for significant demographics, comorbid conditions, adverse symptoms, chronicity, and severity, the results from multilevel random intercept models showed decreased pain (−2.69 points; 95% CI, −2.86 to −2.53; P<.001) and increased physical function (+2.67 points; 95% CI, 2.45-2.89; P<.001) after treatment.

Conclusions

Digital PT was associated with clinically meaningful improvements in pain and function among a diverse set of participants. These early data are an encouraging indicator of the clinical benefit of digital PT.

Physiotherapists' perceptions of how patient adherence and non-adherence to recommended exercise for musculoskeletal conditions affects their practice: a qualitative study

OBJECTIVES

The aim of this study was to explore physiotherapists' perceptions of how patients' adherence and non-adherence to recommended exercise affects their practice.

DESIGN

A qualitative study with a focus group and semi-structured interviews. The focus group and interviews were audio recorded and transcribed verbatim. Transcripts were analysed using thematic analysis.

SETTING

MSK physiotherapy services in the United Kingdom.

PARTICIPANTS

Focus group: 8 UK registered physiotherapists (age range=24-48; seven female, one male). Semi-structured interviews: 10 UK registered physiotherapists (age range=28-52; eight female, two male).

RESULTS

Participants described how exercise adherence could be a challenging aspect of clinical practice and how they tried to improve it. Four main themes were identified: 1) A challenge but worth it; 2) It's frustrating but you can't win them all; 3) Striving to see the individual; and 4) Striving to help the patient. The importance of establishing a good working relationship with patients was emphasised. This included working collaboratively with the patient, avoiding blaming them for non-adherence and thinking about the language they used in discussing exercises.

CONCLUSION

Patient non-adherence to recommended exercise is a challenging aspect of clinical practice. Physiotherapists can acknowledge this difficulty, and the frustrations it may potentially bring, yet remain resilient in the face of it. Clinicians should consider potential approaches and strategies to optimise the potential for behaviour change, and to improve exercise adherence. Robust interventions to help clinicians facilitate better exercise adherence are also needed.

Expanding Role of Technology in Rehabilitation After Lower-Extremity Joint Replacement: A Systematic Review

BACKGROUND

The effectiveness of telehealth programs in the administration of rehabilitation and the monitoring of postoperative progress after joint replacement is not well studied. The purpose of the present study was to systematically review the currently available evidence on the use of smart-device technology and telehealth programs to guide and monitor postoperative rehabilitation following total joint arthroplasty and to assess their impact on outcomes following surgery.

METHODS

A literature search of the MEDLINE database was performed using keywords "mobile," "app," "telehealth," "virtual," "arthroplasty," "outcomes," "joint replacement," "web based," "telemedicine," "TKA," "THA," "activity tracker," "fitness tracker," "monitor," "rehab," "online," and "stepcounter" in all possible combinations. All English studies with a level of evidence of I to III that were published from January 1, 2010, to December 19, 2020 were considered for inclusion. Quantitative and qualitative analysis was performed on the data collected.

RESULTS

A total of 28 articles meeting the inclusion criteria were identified and reviewed. With regard to objective functional outcome measures, such as strength, range of motion, or results of the Timed Up and Go (TUG) test, the virtual physical therapy group had equivalent or slightly superior outcomes compared with in-person physical therapy. There was similar improvement overall in patient-reported outcome measures (PROMs) and patient satisfaction between virtual and in-person physical therapy. Virtual physical therapy resulted in cost savings ranging from $206 to $4,100 per patient compared with in-person physical therapy.

CONCLUSIONS

Telerehabilitation following lower-extremity joint replacement is less expensive compared with in-person physical therapy, with equivalent outcomes and patient satisfaction. Telerehabilitation and electronic health adjuncts can be used to substitute for traditional rehabilitation and augment postoperative care following total joint arthroplasty, respectively. Telerehabilitation that provides outcomes equivalent to in-person physical therapy not only increases convenience for patients but also decreases the cost burden on the health-care system.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Single session compared with multiple sessions of education and exercise for older adults with spinal pain in an advanced practice physiotherapy model of care: protocol for a randomised controlled trial

OBJECTIVES

To assess the effectiveness and cost-effectiveness of a single session compared with multiple sessions of education and exercise for older adults with spinal pain treated conservatively in an advanced practice physiotherapy model of care.

METHODS AND ANALYSIS

In this pragmatic randomised controlled trial, 152 older adults (≥65 years old) with neck or back pain initially referred for a consultation in neurosurgery, but treated conservatively, will be recruited through the advanced practice physiotherapy neurosurgery CareAxis programme in the Montreal region (Quebec, Canada). In the CareAxis programme, older patients with spinal pain are triaged by an advance practice physiotherapist and are offered conservative care and only potential surgical candidates are referred to a neurosurgeon. Participants will be randomised into one of two arms: 1-a single session or 2-multiple sessions (6 sessions over 12 weeks) of education and exercise with the advance practice physiotherapist (1:1 ratio). The primary outcome measure will be the Brief Pain Inventory (pain severity and interference subscales). Secondary measures will include self-reported disability (the Neck Disability Index or Oswestry Disability Index), the Pain Catastrophizing Scale, satisfaction with care questionnaires (9-item Visit-specific Satisfaction Questionnaire and MedRisk), and the EQ-5D-5L. Participants' healthcare resources use and related costs will be measured. Outcomes will be collected at baseline and at 6, 12 and 26 weeks after enrolment. Intention-to-treat analyses will be performed, and repeated mixed-model analysis of variance will assess differences between treatment arms. Cost-utility analyses will be conducted from the perspective of the healthcare system.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Comité d'éthique de la recherche du CIUSS de l'Est-de-l'Île-de-Montréal (FWA00001935 and IRB00002087). Results of this study will be presented to different stakeholders, published in peer-reviewed journals and presented at international conferences.

PROTOCOL VERSION

V.4 August 2021.

TRIAL REGISTRATION NUMBER

NCT04868591; Pre-results.

Factors associated with exercise adherence to prevent or treat neck and low back pain: A systematic review

BACKGROUND

Much attention has been paid to the evaluation of the efficacy of exercise therapy or increasing physical activity with the aim to prevent or alleviate neck and low back pain. However, exercise adherence is necessary for the effective management of neck and low back pain.

OBJECTIVE

We aimed to systematically review randomized controlled trials and cohort studies to gain insights into the factors associated with adherence to exercise or physical activity programs to prevent or treat neck pain and low back pain.

METHOD

Publications were systematically searched from 1980-December 2019 in several databases. The following key words were used: neck pain or low back pain paired with exercise or physical activity and adherence or compliance. Relevant studies were retrieved and assessed for methodological quality by two independent reviewers. Quality of evidence was assessed and rated according to GRADE guidelines.

RESULTS

Nine randomized controlled trials and eight cohort studies were included in this review. Randomized controlled trials indicated moderate-quality evidence for the association between exercise adherence and self-efficacy. Cohort studies showed moderate-quality evidence for the association between exercise adherence and education level.

CONCLUSIONS

Literature investigating factors associated with exercise adherence to prevent or treat neck and low back pain was heterogeneous. Few factors were found to be associated with exercise adherence. More studies are needed before any firm conclusions can be reached.

Hybrid Ubiquitous Coaching With a Novel Combination of Mobile and Holographic Conversational Agents Targeting Adherence to Home Exercises: Four Design and Evaluation Studies

BACKGROUND

Effective treatments for various conditions such as obesity, cardiac heart diseases, or low back pain require not only personal on-site coaching sessions by health care experts but also a significant amount of home exercises. However, nonadherence to home exercises is still a serious problem as it leads to increased costs due to prolonged treatments.

OBJECTIVE

To improve adherence to home exercises, we propose, implement, and assess the novel coaching concept of hybrid ubiquitous coaching (HUC). In HUC, health care experts are complemented by a conversational agent (CA) that delivers psychoeducation and personalized motivational messages via a smartphone, as well as real-time exercise support, monitoring, and feedback in a hands-free augmented reality environment.

METHODS

We applied HUC to the field of physiotherapy and conducted 4 design-and-evaluate loops with an interdisciplinary team to assess how HUC is perceived by patients and physiotherapists and whether HUC leads to treatment adherence. A first version of HUC was evaluated by 35 physiotherapy patients in a lab setting to identify patients' perceptions of HUC. In addition, 11 physiotherapists were interviewed about HUC and assessed whether the CA could help them build up a working alliance with their patients. A second version was then tested by 15 patients in a within-subject experiment to identify the ability of HUC to address adherence and to build a working alliance between the patient and the CA. Finally, a 4-week n-of-1 trial was conducted with 1 patient to show one experience with HUC in depth and thereby potentially reveal real-world benefits and challenges.

RESULTS

Patients perceived HUC to be useful, easy to use, and enjoyable, preferred it to state-of-the-art approaches, and expressed their intentions to use it. Moreover, patients built a working alliance with the CA. Physiotherapists saw a relative advantage of HUC compared to current approaches but initially did not see the potential in terms of a working alliance, which changed after seeing the results of HUC in the field. Qualitative feedback from patients indicated that they enjoyed doing the exercise with an augmented reality-based CA and understood better how to do the exercise correctly with HUC. Moreover, physiotherapists highlighted that HUC would be helpful to use in the therapy process. The longitudinal field study resulted in an adherence rate of 92% (11/12 sessions; 330/360 repetitions; 33/36 sets) and a substantial increase in exercise accuracy during the 4 weeks.

CONCLUSIONS

The overall positive assessments from both patients and health care experts suggest that HUC is a promising tool to be applied in various disorders with a relevant set of home exercises. Future research, however, must implement a variety of exercises and test HUC with patients suffering from different disorders.

Prevention, screening, assessing and managing of non-adherent behaviour in people with rheumatic and musculoskeletal diseases: systematic reviews informing the 2020 EULAR points to consider

OBJECTIVE

To analyse how non-adherence to prescribed treatments might be prevented, screened, assessed and managed in people with rheumatic and musculoskeletal diseases (RMDs).

METHODS

An overview of systematic reviews (SR) was performed in four bibliographic databases. Research questions focused on: (1) effective interventions or strategies, (2) associated factors, (3) impact of shared decision making and effective communication, (4) practical things to prevent non-adherence, (5) effect of non-adherence on outcome, (6) screening and assessment tools and (7) responsible healthcare providers. The methodological quality of the reviews was assessed using AMSTAR-2. The qualitative synthesis focused on results and on the level of evidence attained from the studies included in the reviews.

RESULTS

After reviewing 9908 titles, the overview included 38 SR on medication, 29 on non-pharmacological interventions and 28 on assessment. Content and quality of the included SR was very heterogeneous. The number of factors that may influence adherence exceed 700. Among 53 intervention studies, 54.7% showed a small statistically significant effect on adherence, and all three multicomponent interventions, including different modes of patient education and delivered by a variety of healthcare providers, showed a positive result in adherence to medication. No single assessment provided a comprehensive measure of adherence to either medication or exercise.

CONCLUSIONS

The results underscore the complexity of non-adherence, its changing pattern and dependence on multi-level factors, the need to involve all stakeholders in all steps, the absence of a gold standard for screening and the requirement of multi-component interventions to manage it.

Facilitators and Barriers to Attendance in a Nursing Home Exercise Program

Women and residents in Certified Nursing Homes (CNHs) with higher star ratings had better attendance in exercise and social engagement programming (ie, Bingocize) than men and residents in CNHs with lower ratings.

OBJECTIVE

The purpose of the current study was to determine whether resident factors and nursing home star ratings influenced attendance in Bingocize, a therapeutic exercise program that incorporates opportunities for social engagement in nursing homes.

DESIGN

This is a descriptive study of data collected across multiple nursing homes over 17 months.

SETTING AND PARTICIPANTS

Data were collected from residents in 25 certified nursing homes in the mid-southern United States.

METHODS

The program consisted of two 45-60-minute sessions each week. Bingocize attendance was recoded as number of sessions attended each month from September 2017 to February 2019 in 25 nursing homes. The impact of gender, age, cognitive functioning, and Nursing Home Star Ratings on adherence to the program based on percentage of Bingocize sessions attended was analyzed.

RESULTS

A total of 1165 residents of certified nursing homes were recruited and participated in Bingocize; 55% of participants attended Bingocize infrequently or had poor attendance, 21% of the participants had average attendance, and 24% had good attendance. The association between gender and level of attendance was significant (P = .045). The star rating of the nursing home also affected attendance. As star level of the nursing home increased, the percentage of good attendance increased (P < .001): 19.12% (1 star), 20.69% (2 stars), 23.57% (3 stars), 33.76% (4 stars), and 36.63% (5 stars). Neither age nor cognitive functioning [based on Brief Interview of Mental Status (BIMS)] had a significant impact on attendance.

CONCLUSIONS AND IMPLICATIONS

We examined adherence to an exercise program called Bingocize based on percentage of sessions attended in 25 nursing homes. Women and residents in nursing homes with higher star ratings were reported to have better attendance in Bingocize than men or residents in nursing homes with lower ratings, respectively. Residents of all ages and cognitive ability can successfully participate in the Bingocize program.

A Clinical Comparison of Home-Based and Hospital-Based Exercise Programs Following Arthroscopic Capsulolabral Repair for Anterior Shoulder Instability

Context: Ideal rehabilitation method following arthroscopic capsulolabral repair surgery for anterior shoulder instability has not been proven yet. Although rapid or slow protocols were compared previously, home- or hospital-based protocols were not questioned before. Objective: The aim of this prospective unrandomized controlled clinical trial is to compare the clinical outcomes of home-based and hospital-based rehabilitation programs following arthroscopic Bankart repair. Design: Nonrandomized controlled trial. Setting: Orthopedics and physical therapy units of a single institution. Patients: Fifty-four patients (49 males and 5 females) with an average age of 30.5 (9.1) years, who underwent arthroscopic capsulolabral repair and met the inclusion criteria, with at least 1-year follow-up were allocated into 2 groups: home-based (n = 33) and hospital-based (n = 21) groups. Interventions: Both groups received identical rehabilitation programs. Patients in the home-based group were called for follow-up every 3 weeks. Patients in the hospital-based group admitted for therapy every other day for a total of 6 to 8 weeks. Both groups were followed identically after the eighth week and the rehabilitation program continued for 6 months. Main Outcome Measures: Clinical outcomes were assessed using Disabilities of Arm Shoulder Hand, Constant, and Rowe scores. Mann–Whitney U test was used to compare the results in both groups. Wilcoxon test was used for determining the progress in each group. Results: Groups were age and gender matched (P = .61, P = .69). Average number of treatment sessions was 13.8 (7.3) for patients in the hospital-based group. Preoperative Disabilities of Arm Shoulder Hand (27.46 [11.81] vs 32.53 [16.42], P = .22), Constant (58.23 [14.23] vs 54.17 [10.46], P = .13), and Rowe (51.72 [15.36] vs 43.81 [19.16], P = .12) scores were similar between groups. Postoperative scores at sixth month were significantly improved in each group (P = .001, P = .001, and P = .001). No significant difference was observed between 2 groups regarding clinical scores in any time point. Conclusions: We have, therefore, concluded that a controlled home-based exercise program is as effective as hospital-based rehabilitation following arthroscopic capsulolabral repair for anterior shoulder instability.

Percutaneous Peripheral Nerve Stimulation for Chronic Low Back Pain: Prospective Case Series With 1 Year of Sustained Relief Following Short-Term Implant

INTRODUCTION

Percutaneous peripheral nerve stimulation (PNS) provides an opportunity to relieve chronic low back pain and reduce opioid analgesic consumption as an alternative to radiofrequency ablation and permanently implanted neurostimulation systems. Traditionally, the use of neurostimulation earlier in the treatment continuum has been limited by its associated risk, invasiveness, and cost.

METHODS

Percutaneous PNS leads (SPRINT MicroLead) were placed bilaterally to target the medial branches of the dorsal rami nerves under image guidance. The percutaneous leads were connected to miniature wearable stimulators (SPRINT PNS System) for the 1-month therapy period, after which the leads were removed. Pain and disability were assessed long-term up to 12 months after lead removal.

RESULTS

Substantial, clinically significant reductions in average pain intensity (≥50% reduction as measured by the Brief Pain Inventory Short Form) were experienced by a majority of subjects (67%) at end of treatment compared to baseline (average 80% reduction among responders; P < 0.05, analysis of variance; n = 9). Twelve months after the end of PNS treatment, a majority of subjects who completed the long-term follow-up visits experienced sustained, clinically significant reductions in pain and/or disability (67%, n = 6; average 63% reduction in pain intensity and 32-point reduction in disability among responders). No serious or unanticipated adverse events were reported.

CONCLUSIONS

This study challenges the long-held notion that a positive trial of PNS should be followed by a permanent implant in responders. Percutaneous PNS may serve as an effective neurostimulation therapy for patients with chronic low back pain and should be considered earlier in the treatment continuum as a motor-sparing means of avoiding opioids, denervation, and permanently implanted neurostimulation systems.

Characteristics associated with high levels of patient-reported adherence to self-management strategies prescribed by physiotherapists

Background/aims

Physiotherapist-prescribed self-management strategies are an important component of physiotherapy practice but they can only be effective if patients adhere. The aim of this study was to explore patient-reported adherence to physiotherapist-prescribed self-management strategies, and the extent to which patient, physiotherapist, consultation and prescription characteristics are associated with high levels of adherence.

Methods

A cross-sectional observational study across four private practices; including 14 physiotherapists and 113 patients was conducted. Data were collected in two stages. The first stage consisted of observing a patient at their physiotherapist consultation to collect data regarding the physiotherapist's prescription of self-management strategies. The second stage consisted of a follow-up telephone interview with each observed patient to record the patient-reported level of adherence to each prescribed self-management strategy.

Results

Prescribed self-management strategies where physiotherapists asked patients to repeat details of the self-management strategy were 6.54 times (95% confidence interval 2.91–14.98) more likely to be highly adhered to than strategies where the physiotherapist did not do this. Prescribed strategies accompanied by printed information were 2.73 times (95% confidence interval 1.24–6.00) more likely to be highly adhered to than strategies that were not. Advice such as to rest from activity (odds ratio=0.18; 95% confidence interval 0.08–0.40) was less likely to be highly adhered to when compared to home-based exercise programmes.

Conclusions

To improve patient-reported adherence to self-management strategies, physiotherapists should be encouraged to provide supplementary printed information and ask their patients to repeat details of the prescribed strategy.

Do sociodemographic features, pain sensitivity or pain catastrophizing relate to clinic-based adherence to physiotherapy in people suffering from chronic spinal pain? Secondary analysis of a randomized clinical trial

PURPOSE

Examining whether socio-demographic variables, pain or functionality are related to the degree of clinic-based therapy adherence in patients suffering from nonspecific chronic spinal pain (nCSP).

DESIGN

Secondary analysis of a randomized clinical trial.

SETTING

University hospital of Ghent and Brussels.

METHODS

Dutch speakers, 18-65 years old, experiencing nCSP for at least 3 months. 120 participants were randomly allocated to two interventional groups, of which 94 completed all therapy sessions.

MAIN OUTCOME MEASURES

Degree of clinic-based adherence, defined as the amount of completed therapy sessions.

RESULTS

Demographic data (sex, age or education) were not significantly associated with adherence in the total sample or the neuroscience group. For the traditional physiotherapy group, educational level was associated with attendance of at least 50% of the therapy sessions. Regarding pain-, belief- and function-related measures, only the association between change in kinesiophobia and adherence was significant for the traditional physiotherapy group.

CONCLUSIONS

Factors related to therapy adherence in the total group or the neuroscience group could not be found. Educational level and change in kinesiophobia were however related to therapy adherence in the traditional physiotherapy group.

Wearable Sensor-Based Exercise Biofeedback for Orthopaedic Rehabilitation: A Mixed Methods User Evaluation of a Prototype System

The majority of wearable sensor-based biofeedback systems used in exercise rehabilitation lack end-user evaluation as part of the development process. This study sought to evaluate an exemplar sensor-based biofeedback system, investigating the feasibility, usability, perceived impact and user experience of using the platform. Fifteen patients participated in the study having recently undergone knee replacement surgery. Participants were provided with the system for two weeks at home, completing a semi-structured interview alongside the System Usability Scale (SUS) and user version of the Mobile Application Rating Scale (uMARS). The analysis from the SUS (mean = 90.8 [SD = 7.8]) suggests a high degree of usability, supported by qualitative findings. The mean adherence rate was 79% with participants reporting a largely positive user experience, suggesting it offers additional support with the rehabilitation regime. Overall quality from the mean uMARS score was 4.1 out of 5 (SD = 0.39), however a number of bugs and inaccuracies were highlighted along with suggestions for additional features to enhance engagement. This study has shown that patients perceive value in the use of wearable sensor-based biofeedback systems and has highlighted the benefit of user-evaluation during the design process, illustrated the need for real-world accuracy validation, and supports the ongoing development of such systems.

Associated factors with adherence to standard exercise therapy and health-related quality of life in Chinese patients with ankylosing spondylitis

Objectives: The aim of this study is to assess the current situations of standard exercise treatment and predictors of non-standard exercise in Chinese patients with ankylosing spondylitis (AS). An analysis of the effect of standard exercise on health-related quality of life (HR-QoL) was also conducted.Methods: In the cross-sectional study, a total of 259 AS patients were constantly invited to participate in this study and complete the questionnaire under the researchers' supervision in a clinical setting including sociodemographic variables, clinical variables, psychological variables, and HR-QoL. Data were analyzed by Mann-Whitney U test, Chi-square test as well as multivariable analysis of Binary Stepwise Logistic Regression.Results: The data showed that just 20.5% of them could complete the standard exercise. Exercise adherence was associated with employment, educational level, marital status, place of residence, treatment of Tumor Necrosis Factor-α inhibitor, knowledge about exercise, disease duration, clinical variables, and anxiety. The HR-QoL in the group of standard exercise was better than that in the non-standard exercise group. Logistic Regression Analysis showed that lower educational level, less knowledge about benefits of exercise treatment and higher score of Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) were the independent risk factors of exercise treatment non-adherence.Conclusion: AS patients educated less than 9 years or with higher BASDAI score were more likely not to adhere to standard exercise treatment. Non-adherence to exercise treatment among AS patients is exceedingly common, particularly in patients without knowledge about benefits of exercise treatment. Standard exercise treatment can also improve HR-QoL of AS patients.

Patient adherence to an exercise program for chronic low back pain measured by patient-report, physiotherapist-perception and observational data

The effectiveness of exercise programs for chronic low back pain (CLBP) is dependent upon patient adherence which is problematic to measure accurately. This cross-sectional observational study aimed to compare patient-reported levels of adherence with physiotherapists' perceptions of patient adherence; and to explore the proportion of patients who could accurately recall and demonstrate the exercises contained within their prescribed exercise program for CLBP. Participating patients (n = 61) included those attending for a follow-up consultation with a physiotherapist (n = 15) at a consenting practice (n = 6) who had been prescribed an exercise program for CLBP. Patients were asked to self-report their level of adherence to the exercise program which was then compared to their physiotherapist's perception of adherence. Patients were also asked to recall and demonstrate the exercise program to an independent researcher, which was compared to the prescribed program. Results indicated that in total, 24 patients (39%; 95% CI: 27-52%) self-reported as being completely adherent compared with 10 patients (16%; 95% CI: 8-28%) who were perceived by their physiotherapists as completely adherent (raw agreement: 0.21). However, only nine patients (15%, 95% CI: 7-26%) were able to accurately recall and demonstrate their prescribed exercise program to the researcher, of which eight of these nine patients self-reported complete adherence to the exercise program. In comparison, only four of these nine patients were perceived by the physiotherapist to be completely adherent. These results suggest that patient adherence to home-based exercise programs for CLBP might be assessed more accurately using multi-faceted measures which include an observational component.

Mental models of adherence: parallels in perceptions, values, and expectations in adherence to prescribed home exercise programs and other personal regimens

Purpose: A mental model is the collection of an individual's perceptions, values, and expectations about a particular aspect of their life, which strongly influences behaviors. This study explored orthopedic outpatients mental models of adherence to prescribed home exercise programs and how they related to mental models of adherence to other types of personal regimens. Methods: The study followed an interpretive description qualitative design. Data were collected via two semi-structured interviews. Interview One focused on participants prior experiences adhering to personal regimens. Interview Two focused on experiences adhering to their current prescribed home exercise program. Data analysis followed a constant comparative method. Results: Findings revealed similarity in perceptions, values, and expectations that informed individuals mental models of adherence to personal regimens and prescribed home exercise programs. Perceived realized results, expected results, perceived social supports, and value of convenience characterized mental models of adherence. Conclusion: Parallels between mental models of adherence for prescribed home exercise and other personal regimens suggest that patients adherence behavior to prescribed routines may be influenced by adherence experiences in other aspects of their lives. By gaining insight into patients adherence experiences, values, and expectations across life domains, clinicians may tailor supports that enhance home exercise adherence. Implications for Rehabilitation A mental model is the collection of an individual's perceptions, values, and expectations about a particular aspect of their life, which is based on prior experiences and strongly influences behaviors. This study demonstrated similarity in orthopedic outpatients mental models of adherence to prescribed home exercise programs and adherence to personal regimens in other aspects of their lives. Physical therapists should inquire about patients non-medical adherence experiences, as strategies patients customarily use to adhere to other activities may inform strategies to promote prescribed home exercise adherence.

Outcome measures for adherence to home exercises among patients with chronic low back pain: a systematic review

[Purpose] The aim of this study was to investigate what outcome measures are reliable in the evaluation of adherence to home exercises among patients with chronic low back pain. [Methods] A systematic review on articles related to adherence to home exercises for patients with chronic low back pain was conducted, and outcome measures and psychometric properties were extracted and evaluated in terms of validity and reliability. [Results] A total of 4,583 articles were identified, and eight articles were finally included after screening. The identified outcome measures were self-reported frequency, duration and intensity of home exercises and Treatment Self-Regulation Questionnaire results. Although the internal consistency and criterion validity of the Treatment Self-Regulation Questionnaire results have been proven in the literature, none of the included articles validated the self-reported frequency, duration, and intensity of the home exercises. [Conclusion] Only the Treatment Self-Regulation Questionnaire results were found to be a reliable measure, and further research to validate self-reported outcome measures is required.

Patient Involvement With Home-Based Exercise Programs: Can Connected Health Interventions Influence Adherence?

Adherence to home exercise in rehabilitation is a significant problem, with estimates of nonadherence as high as 50%, potentially having a detrimental effect on clinical outcomes. In this viewpoint, we discuss the many reasons why patients may not adhere to a prescribed exercise program and explore how connected health technologies have the ability to offer numerous interventions to enhance adherence; however, it is hard to judge the efficacy of these interventions without a robust measurement tool. We highlight how well-designed connected health technologies, such as the use of mobile devices, including mobile phones and tablets, as well as inertial measurement units, provide us with the opportunity to better support the patient and clinician, with a data-driven approach that incorporates features designed to increase adherence to exercise such as coaching, self-monitoring and education, as well as remotely monitor adherence rates more objectively.

What interventions are used to improve exercise adherence in older people and what behavioural techniques are they based on? A systematic review

OBJECTIVES

To conduct a systematic review of interventions used to improve exercise adherence in older people, to assess the effectiveness of these interventions and to evaluate the behavioural change techniques underpinning them using the Behaviour Change Technique Taxonomy (BCTT).

DESIGN

Systematic review.

METHODS

A search was conducted on AMED, BNI, CINAHL, EMBASE, MEDLINE and PsychINFO databases. Randomised controlled trials that used an intervention to aid exercise adherence and an exercise adherence outcome for older people were included. Data were extracted with the use of a preprepared standardised form. Risk of bias was assessed with the Cochrane Collaboration's tool for assessing risk of bias. Interventions were classified according to the BCTT.

RESULTS

Eleven studies were included in the review. Risk of bias was moderate to high. Interventions were classified into the following categories: comparison of behaviour, feedback and monitoring, social support, natural consequences, identity and goals and planning. Four studies reported a positive adherence outcome following their intervention. Three of these interventions were categorised in the feedback and monitoring category. Four studies used behavioural approaches within their study. These were social learning theory, socioemotional selectivity theory, cognitive behavioural therapy and self-efficacy. Seven studies did not report a behavioural approach.

CONCLUSIONS

Interventions in the feedback and monitoring category showed positive outcomes, although there is insufficient evidence to recommend their use currently. There is need for better reporting, use and the development of theoretically derived interventions in the field of exercise adherence for older people. Robust measures of adherence, in order to adequately test these interventions would also be of use.

PROSPERO REGISTRATION NUMBER

CRD42015020884.

Unsupervised progressive elastic band exercises for frail geriatric inpatients objectively monitored by new exercise-integrated technology-a feasibility trial with an embedded qualitative study

BACKGROUND

Frailty is a serious condition frequently present in geriatric inpatients that potentially causes serious adverse events. Strength training is acknowledged as a means of preventing or delaying frailty and loss of function in these patients. However, limited hospital resources challenge the amount of supervised training, and unsupervised training could possibly supplement supervised training thereby increasing the total exercise dose during admission. A new valid and reliable technology, the BandCizer, objectively measures the exact training dosage performed. The purpose was to investigate feasibility and acceptability of an unsupervised progressive strength training intervention monitored by BandCizer for frail geriatric inpatients.

METHODS

This feasibility trial included 15 frail inpatients at a geriatric ward. At hospitalization, the patients were prescribed two elastic band exercises to be performed unsupervised once daily. A BandCizer Datalogger enabling measurement of the number of sets, repetitions, and time-under-tension was attached to the elastic band. The patients were instructed in performing strength training: 3 sets of 10 repetitions (10-12 repetition maximum (RM)) with a separation of 2-min pauses and a time-under-tension of 8 s. The feasibility criterion for the unsupervised progressive exercises was that 33% of the recommended number of sets would be performed by at least 30% of patients. In addition, patients and staff were interviewed about their experiences with the intervention.

RESULTS

Four (27%) out of 15 patients completed 33% of the recommended number of sets. For the total sample, the average percent of performed sets was 23% and for those who actually trained (n = 12) 26%. Patients and staff expressed a general positive attitude towards the unsupervised training as an addition to the supervised training sessions. However, barriers were also described-especially constant interruptions.

CONCLUSIONS

Based on the predefined criterion for feasibility, the unsupervised training was not feasible, although the criterion was almost met. The patients and staff mainly expressed positive attitudes towards the unsupervised training. As even a small training dosage has been shown to improve the physical performance of geriatric inpatients, the proposed intervention might be relevant if the interruptions are decreased in future large-scale trials and if the adherence is increased.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02702557, February 29, 2016. Data Protection Agency: 2016-42, February 25, 2016. Ethics Committee: No registration needed, December 8, 2015 (e-mail correspondence).

Percutaneous Peripheral Nerve Stimulation for the Treatment of Chronic Low Back Pain: Two Clinical Case Reports of Sustained Pain Relief

As the leading cause of disability among U.S. adults, chronic low back pain (LBP) is one of the most prevalent and challenging musculoskeletal conditions. Neuromodulation provides an opportunity to reduce or eliminate the use of opioids to treat chronic LBP, but the cost and invasiveness of existing methods have limited its broad adoption, especially earlier in the treatment continuum. The present case report details the results of a novel method of short-term percutaneous peripheral nerve stimulation (PNS) in 2 subjects with chronic LBP. At the end of the 1-month therapy, stimulation was discontinued and the leads were withdrawn. PNS produced clinically significant improvements in pain (62% average reduction in Brief Pain Inventory Question #5, average pain), and functional outcomes (73% reduction in disability, Oswestry Disability Index; 83% reduction in pain interference, Brief Pain Inventory). Both subjects reduced nonopioid analgesic use by 83%, on average, and the one subject taking opioids ceased using all opioids. The only adverse event was minor skin irritation caused by a topical dressing. The clinically significant improvements were sustained at least 4 months after start of therapy (79% average reduction in pain; both reported minimal disability; 100% reduction in opioids; 74% reduction nonopioids). The results reveal the utility of this novel, short-term approach and its potential as a minimally invasive neuromodulation therapy for use earlier in the treatment continuum to produce sustained pain relief and reduce or eliminate the need for analgesic medications, including opioids, as well as more expensive and invasive surgical or therapeutic alternatives.

Structured Wii protocol for rehabilitation of shoulder impingement syndrome: A pilot study

OBJECTIVE

To determine the feasibility and efficacy of using a structured Nintendo Wii protocol to improve range of motion, strength, and quality of life in patients with shoulder impingement syndrome.

METHODS

A total of 14 patients with shoulder pain were randomized to perform a structured Wii protocol (n=8) or conventional therapy (n=6). Pain-free shoulder range of motion, strength, shoulder pain and disability, and quality of life were assessed pre- and post-treatment.

RESULTS

All 8 patients completed the Wii protocol, and 3 completed conventional therapy. The Wii protocol conferred significant improvements in shoulder range of motion, pain and disability, and quality of life but not strength, whereas conventional therapy conferred a significant improvement in strength.

CONCLUSIONS

As compared to conventional treatment, the structured Wii protocol implemented in this pilot study was a viable adjunct to therapy for shoulder impingement syndrome. Gaming may have a supplemental benefit by increasing motivation, pleasure, and/or adherence. Further investigation in larger cohorts is warranted.

How Do Physical Therapists Treat People with Knee Osteoarthritis, and What Drives Their Clinical Decisions? A Population-Based Cross-Sectional Survey

Purpose: It is unclear how physical therapists in Florida currently treat people with knee osteoarthritis and whether current best evidence is used in clinical decision making. Methods: We conducted a survey of physical therapists in Florida. We assessed the perceived effectiveness and actual use of physical therapy (PT) interventions and quantified the association between the actual use of interventions and different characteristics of physical therapists. Results: A total of 413 physical therapists completed the survey. Most respondents perceived therapeutic exercise (94%) and education (93%) as being effective or very effective. Interventions least perceived as effective or very effective were electrotherapy (28%), wedged insole (20%), and ultrasound (19%). Physical therapists who followed the principles of evidence-based practice were more likely to use therapeutic exercise (OR 3.89; 95% CI: 1.21, 12.54) and education (OR 3.63; 95% CI: 1.40, 9.43) and less likely to use ultrasound (OR 0.32; 95% CI: 0.16, 0.63) and electrotherapy (OR 0.32; 95% CI: 0.17, 0.58). Results also indicated that older physical therapists were more likely to use ultrasound (OR 3.57; 95% CI: 1.60, 7.96), electrotherapy (OR 2.53; 95% CI: 1.17, 5.47), kinesiology tape (OR 3.82; 95% CI: 1.59, 9.18), and ice (OR 1.95; 95% CI: 1.02, 3.73). Conclusions: In line with clinical guidelines, most physical therapists use therapeutic exercise and education to treat people with knee osteoarthritis. However, interventions that lack scientific support, such as electrotherapy and ultrasound, are still used. A modifiable therapist characteristic, adherence to evidence-based practice, is positively associated with the use of interventions supported by scientific evidence.

Predictors of adherence to home-based physical therapies: a systematic review

PURPOSE

Self-managed, home-based physical therapy (HBPT) is an increasingly common element of physical therapy rehabilitation programmes but non-adherence can reach 70%. Understanding factors that influence patients' adherence to HBPTs could help practitioners support better adherence. Research to date has focussed largely on clinic-based physiotherapy. The objective of this review, therefore, was to identify specific factors, which influence adherence to home-based, self-managed physical therapies.

METHOD

A systematic review was conducted, in which eight online databases were searched using combinations of key terms relating to physical therapies, adherence and predictors. Matching records were screened against eligibility criteria and 30 quantitative articles were quality assessed and included in the final review. Relevant data were extracted and a narrative synthesis approach was taken to aggregating findings across studies.

RESULTS

There was relatively strong evidence that the following factors predicted adherence to HBPTs: intention to engage in the HBPT, self-motivation, self-efficacy, previous adherence to exercise-related behaviours and social support.

CONCLUSIONS

This review has identified a range of factors that appear to be related to patients' adherence to their self-managed physical rehabilitation therapies. Awareness of these factors may inform design of interventions to improve adherence. Implications for Rehabilitation Non-adherence to physical rehabilitation therapies is often high - particularly in self-managed, home-based programmes, despite good adherence being important in achieving positive outcomes. The findings of this systematic review indicate that greater self-efficacy, self-motivation, social support, intentions and previous adherence to physical therapies predict higher adherence to HBPTs. Assessment of these domains before providing individuals with their HBPT regimes may allow identification of 'risk factors' for poor adherence. These can then potentially be addressed or managed prior to, or alongside, the therapy. Interventions to support patients' self-managed physical rehabilitation should include elements designed to enhance patients' self-efficacy, self-motivation and social support given the evidence that these factors are good predictors of adherence.

Appointment reminder systems are effective but not optimal: results of a systematic review and evidence synthesis employing realist principles

Missed appointments are an avoidable cost and resource inefficiency which impact upon the health of the patient and treatment outcomes. Health care services are increasingly utilizing reminder systems to manage these negative effects. This study explores the effectiveness of reminder systems for promoting attendance, cancellations, and rescheduling of appointments across all health care settings and for particular patient groups and the contextual factors which indicate that reminders are being employed sub-optimally. We used three inter-related reviews of quantitative and qualitative evidence. Firstly, using pre-existing models and theories, we developed a conceptual framework to inform our understanding of the contexts and mechanisms which influence reminder effectiveness. Secondly, we performed a review following Centre for Reviews and Dissemination guidelines to investigate the effectiveness of different methods of reminding patients to attend health service appointments. Finally, to supplement the effectiveness information, we completed a review informed by realist principles to identify factors likely to influence non-attendance behaviors and the effectiveness of reminders. We found consistent evidence that all types of reminder systems are effective at improving appointment attendance across a range of health care settings and patient populations. Reminder systems may also increase cancellation and rescheduling of unwanted appointments. "Reminder plus", which provides additional information beyond the reminder function may be more effective than simple reminders (ie, date, time, place) at reducing non-attendance at appointments in particular circumstances. We identified six areas of inefficiency which indicate that reminder systems are being used sub-optimally. Unless otherwise indicated, all patients should receive a reminder to facilitate attendance at their health care appointment. The choice of reminder system should be tailored to the individual service. To optimize appointment and reminder systems, health care services need supportive administrative processes to enhance attendance, cancellation, rescheduling, and re-allocation of appointments to other patients.

Structural integration as an adjunct to outpatient rehabilitation for chronic nonspecific low back pain: a randomized pilot clinical trial

Structural Integration (SI) is an alternative method of manipulation and movement education. To obtain preliminary data on feasibility, effectiveness, and adverse events (AE), 46 outpatients from Boston area with chronic nonspecific low back pain (CNSLBP) were randomized to parallel treatment groups of SI plus outpatient rehabilitation (OR) versus OR alone. Feasibility data were acceptable except for low compliance with OR and lengthy recruitment time. Intent-to-treat data on effectiveness were analyzed by Wilcoxon rank sum, n = 23 per group. Median reductions in VAS Pain, the primary outcome, of -26 mm in SI + OR versus 0 in OR alone were not significantly different (P = 0.075). Median reductions in RMDQ, the secondary outcome, of -2 points in SI + OR versus 0 in OR alone were significantly different (P = 0.007). Neither the proportions of participants with nor the seriousness of AE were significantly different. SI as an adjunct to OR for CNSLBP is not likely to provide additional reductions in pain but is likely to augment short term improvements in disability with a low additional burden of AE. A more definitive trial is feasible, but OR compliance and recruitment might be challenging. This trial is registered with ClinicalTrials.gov (NCT01322399).

Patients' mental models and adherence to outpatient physical therapy home exercise programs

Within physical therapy, patient adherence usually relates to attending appointments, following advice, and/or undertaking prescribed exercise. Similar to findings for general medical adherence, patient adherence to physical therapy home exercise programs (HEP) is estimated between 35 and 72%. Adherence to HEPs is a multifactorial and poorly understood phenomenon, with no consensus regarding a common theoretical framework that best guides empirical or clinical efforts. Mental models, a construct used to explain behavior and decision-making in the social sciences, may serve as this framework. Mental models comprise an individual's tacit thoughts about how the world works. They include assumptions about new experiences and expectations for the future based on implicit comparisons between current and past experiences. Mental models play an important role in decision-making and guiding actions. This professional theoretical article discusses empirical research demonstrating relationships among mental models, prior experience, and adherence decisions in medical and physical therapy contexts. Specific issues related to mental models and physical therapy patient adherence are discussed, including the importance of articulation of patients' mental models, assessment of patients' mental models that relate to exercise program adherence, discrepancy between patient and provider mental models, and revision of patients' mental models in ways that enhance adherence. The article concludes with practical implications for physical therapists and recommendations for further research to better understand the role of mental models in physical therapy patient adherence behavior.

The impact of hospital-based and community based models of cerebral palsy rehabilitation: a quasi-experimental study

BACKGROUND

Cerebral palsy requires appropriate on-going rehabilitation intervention which should effectively meet the needs of both children and parents/care-givers. The provision of effective support is a challenge, particularly in resource constrained settings. A quasi-experimental pragmatic research design was used to compare the impact of two models of rehabilitation service delivery currently offered in Harare, Zimbabwe, an outreach-based programme and the other institution-based.

METHOD

Questionnaires were distributed to 46 caregivers of children with cerebral palsy at baseline and after three months. Twenty children received rehabilitation services in a community setting and 26 received services as outpatients at a central hospital. The Gross Motor Function Measurement was used to assess functional change. The burden of care was measured using the Caregiver Strain Index, satisfaction with physiotherapy was assessed using the modified Medrisk satisfaction with physiotherapy services questionnaire and compliance was measured as the proportion met of the scheduled appointments.

RESULTS

Children receiving outreach-based treatment were significantly older than children in the institution-based group. Regression analysis revealed that, once age and level of severity were controlled for, children in the outreach-based treatment group improved their motor function 6% more than children receiving institution-based services. There were no differences detected between the groups with regard to caregiver well-being and 51% of the caregivers reported signs consistent with clinical distress/depression. Most caregivers (83%) expressed that they were overwhelmed by the caregiving role and this increased with the chronicity of care. The financial burden of caregiver was predictive of caregiver strain. Caregivers in the outreach-based group reported greater satisfaction with services and were more compliant (p < .001) as compared to recipients of institution-based services.

CONCLUSION

Long term caregiving leads to strain in caregivers and there is a need to design interventions to alleviate the burden. The study was a pragmatic, quasi-experimental study thus causality cannot be inferred. However findings from this study suggest that the provision of care within a community setting as part of a well-structured outreach programme may be preferable method of service delivery within a resource-constrained context. It was associated with a greater improvement in functioning, greater satisfaction with services and better compliance.

Targeting the Use of Reminders and Notifications for Uptake by Populations (TURNUP): a systematic review and evidence synthesis

Background

Missed appointments are an avoidable cost and a resource inefficiency that impact on the health of the patient and treatment outcomes. Health-care services are increasingly utilising reminder systems to counter these negative effects.

Objectives

This project explores the differential effect of reminder systems for different segments of the population for improving attendance, cancellation and rescheduling of appointments.

Design

Three inter-related reviews of quantitative and qualitative evidence relating to theoretical explanations for appointment behaviour (review 1), the effectiveness of different approaches to reminding patients to attend health service appointments (review 2) and factors likely to influence non-attendance (review 3).

Data sources

Database searches were conducted on Allied and Complementary Medicine, Cumulative Index to Nursing and Allied Health Literature Plus with Full Text, The Cochrane Library, EMBASE (via NHS Evidence from 1 January 2000 to January/February 2012), Health Management Information Consortium database, Institute of Electrical and Electronics EngineersXplore, The King’s Fund Library Catalogue, Maternity and Infant Care, MEDLINE, Physiotherapy Evidence Database, PsycINFO, SPORTDiscus and Web of Science from 1 January 2000 to January/February 2012. Supplementary screening of references of included studies was conducted to identify additional potentially relevant studies. Conceptual papers were identified for review 1, randomised controlled trials (RCTs) and systematic reviews for review 2 and a range of quantitative and qualitative research designs for review 3.

Methods

We conducted three inter-related reviews of quantitative and qualitative evidence, involving a review of conceptual frameworks of reminder systems and adherence behaviours, a review of the reminder effectiveness literature and a review informed by realist principles to explain the contexts and mechanisms that explain reminder effectiveness. A preliminary conceptual framework was developed to show how reminder systems work, for whom they work and in which circumstances. Six themes emerged that potentially influence the effectiveness of the reminder or whether or not patients would attend their appointment, namely the reminder–patient interaction, reminder accessibility, health-care settings, wider social issues, cancellation and rebookings, and distal/proxy attributes. Standardised review methods were used to investigate the effectiveness of reminders to promote attendance, cancellation or rebooking across all outpatient settings. Finally, a review informed by realist principles was undertaken, using the conceptual framework to explain the context and mechanisms that influence how reminders support attendance, cancellation and rebooking.

Results

A total of 466 papers relating to 463 studies were identified for reviews 2 and 3. Findings from 31 RCTs and 11 separate systematic reviews (review 2 only) revealed that reminder systems are consistently effective at reducing non-attendance at appointments, regardless of health-care setting or patient subgroups. Simple reminders that provide details of timing and location of appointments are effective for increasing attendance at appointments. Reminders that provide additional information over and above the date, time and location of the appointment (‘reminder plus’) may be more effective than simple reminders at reducing non-attendance and may be particularly useful for first appointments and screening appointments; simple reminders may be appropriate thereafter for most patients the majority of the time. There was strong evidence that the timing of reminders, between 1 and 7 days prior to the appointment, has no effect on attendance; substantial numbers of patients do not receive their reminder; reminders promote cancellation of appointments; inadequate structural factors prevent patients from cancelling appointments; and few studies investigated factors that influence the effectiveness of reminder systems for population subgroups.

Limitations

Generally speaking, the systematic review method seeks to provide a precise answer to a tightly focused question, for which there is a high degree of homogeneity within the studies. A wide range of population types, intervention, comparison and outcomes is included within the RCTs we identified. However, use of this wider approach offers greater analytical capability in terms of understanding contextual and mechanistic factors that would not have been evident in a more narrowly focused review and increases confidence that the findings will have relevance in a wide range of service settings.

Conclusions

Simple reminders or ‘reminder plus’ should be sent to all patients in the absence of any clear contraindication. Other reminder alternatives may be relevant for key groups of patients: those from a deprived background, ethnic minorities, substance abusers and those with comorbidities and/or illnesses. We are developing a practice guideline that may help managers to further tailor their reminder systems for their service and client groups. We recommend future research activities in three main areas. First, more studies should routinely consider the potential for differential effects of reminder systems between patient groups in order to identify any inequalities and remedies. Second, ‘reminder plus’ systems appear promising, but there is a need for further research to understand how they influence attendance behaviour. Third, further research is required to identify strategies to ‘optimise’ reminder systems and compare performance with current approaches.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A systematic review of measures of self-reported adherence to unsupervised home-based rehabilitation exercise programmes, and their psychometric properties

BACKGROUND

Adherence is an important factor contributing to the effectiveness of exercise-based rehabilitation. However, there appears to be a lack of reliable, validated measures to assess self-reported adherence to prescribed but unsupervised home-based rehabilitation exercises.

OBJECTIVES

A systematic review was conducted to establish what measures were available and to evaluate their psychometric properties.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO CINAHL (June 2013) and the Cochrane library were searched (September 2013). Reference lists from articles meeting the inclusion criteria were checked to ensure all relevant papers were included.

STUDY SELECTION

To be included articles had to be available in English; use a self-report measure of adherence in relation to a prescribed but unsupervised home-based exercise or physical rehabilitation programme; involve participants over the age of 18. All health conditions and clinical populations were included.

DATA EXTRACTION

Descriptive data reported were collated on a data extraction sheet. The measures were evaluated in terms of eight psychometric quality criteria.

RESULTS

58 studies were included, reporting 61 different measures including 29 questionnaires, 29 logs, two visual analogue scales and one tally counter. Only two measures scored positively for one psychometric property (content validity). The majority of measures had no reported validity or reliability testing.

CONCLUSIONS

The results expose a gap in the literature for well-developed measures that capture self-reported adherence to prescribed but unsupervised home-based rehabilitation exercises.

An application of the health action process approach to physiotherapy rehabilitation adherence

This study tested the utility of an extended version of the health action process approach (HAPA) to explain the attitudinal and behavioural processes contributing to rehabilitation adherence and ultimately rehabilitation outcomes in physiotherapy patients. The HAPA focuses on self-efficacy, action and coping planning and their relationships to behavioural intentions and actual behaviour. A one group prospective design was employed in which 20 participants with soft tissue injuries of the shoulder were followed for the first four weeks of their clinic- and home-based physiotherapy. Participants enrolled in the study after their first physiotherapy clinic appointment, at which time they completed questionnaires measuring the motivational HAPA constructs and shoulder function. Action and coping plans were then made with assistance of the researcher. Adherence behaviours were measured throughout the study, and at the end the volitional stage HAPA constructs, action self-efficacy and shoulder function were assessed. Moderate to strong correlations occurred between the self-efficacies and behavioural intentions, behavioural intentions and adherence behaviours, and adherence behaviours and post-study shoulder function. These findings support the extension of the HAPA model to include the functional outcomes for soft tissue injuries of the shoulder. Its true value will nevertheless only be realized in a longer duration study with a larger sample size.

Negative affect and sleep disturbance may be associated with response to epidural steroid injections for spine-related pain

OBJECTIVE

To describe whether negative affect and sleep impairment are associated with the clinical effect of epidural steroid injections (ESIs) for low back pain.

DESIGN

Observational study; patients were evaluated before ESI and 1 and 3 months after ESI.

SETTING

Spine center and related treatment sites.

PARTICIPANTS

Participants (N=158) seeking treatment for low back pain with or without radiculopathy.

INTERVENTION

ESI for low back pain with or without radiculopathy.

MAIN OUTCOME MEASURES

We assessed the dependent (global pain severity for back and leg pain, pain behavior, pain interference) and independent variables (depression, sleep disturbance, and covariates of back pain response) with the Patient-Reported Outcome Measurement Information System (PROMIS) and legacy measures. Outcome was assessed cross-sectionally using multiple regression and longitudinally with path analysis.

RESULTS

After 1 month, sleep disturbance was the only predictor for the global ratings of improvement in back pain (R(2)=16.8%) and leg pain (R(2)=11.4%). The proportions of variance explained by sleep disturbance and negative affect for all dependent variables were greater at 3 months than 1 month. Mediation analysis was significant for negative affect for the 3-month outcomes on PROMIS pain behavior (β=.87, P<.01) and pain interference (β=.37, P<.01). There was no evidence of mediation by sleep disturbance for any outcome.

CONCLUSIONS

Negative affect and sleep disturbance are associated with worse outcomes after ESI. Further research is needed to determine if treatment of negative affect and sleep disturbance prior to or concurrently with ESI will improve outcomes.

Exercise and Auricular Acupuncture for Chronic Low-back Pain: A Feasibility Randomized-controlled Trial

OBJECTIVES

To evaluate the feasibility of a randomized-controlled trial (RCT) investigating the effects of adding auricular acupuncture (AA) to exercise for participants with chronic low-back pain (CLBP).

METHODS

Participants with CLBP were recruited from primary care and a university population and were randomly allocated (n=51) to 1 of 2 groups: (1) "Exercise Alone (E)"-12-week program consisting of 6 weeks of supervised exercise followed by 6 weeks unsupervised exercise (n=27); or (2) "Exercise and AA (EAA)"-12-week exercise program and AA (n=24). Outcome measures were recorded at baseline, week 8, week 13, and 6 months. The primary outcome measure was the Oswestry Disability Questionnaire.

RESULTS

Participants in the EAA group demonstrated a greater mean improvement of 10.7% points (95% confidence interval, -15.3,-5.7) (effect size=1.20) in the Oswestry Disability Questionnaire at 6 months compared with 6.7% points (95% confidence interval, -11.4,-1.9) in the E group (effect size=0.58). There was also a trend towards a greater mean improvement in quality of life, LBP intensity and bothersomeness, and fear-avoidance beliefs in the EAA group. The dropout rate for this trial was lower than anticipated (15% at 6 mo), adherence with exercise was similar (72% E; 65% EAA). Adverse effects for AA ranged from 1% to 14% of participants.

DISCUSSION

Findings of this study showed that a main RCT is feasible and that 56 participants per group would need to be recruited, using multiple recruitment approaches. AA was safe and demonstrated additional benefits when combined with exercise for people with CLBP, which requires confirmation in a fully powered RCT.

A critical review of the evidence on the use of videotapes or DVD to promote patient compliance with home programmes

PURPOSE

The purpose of this paper is to critically review published research in order to evaluate the evidence surrounding the provision of video or DVD technology to promote patient compliance with home exercise or health programmes.

METHOD

A literature search of the MEDLINE, CINAHL and Cochrane databases was undertaken. Critical appraisal of selected studies was undertaken using a previously validated tool. Inclusion criteria were: research related to DVD or videotape technology to improve compliance; published in peer-reviewed journals and full-text English language articles. Compliance was the main outcome measure.

RESULTS

Eleven eligible studies were reviewed. All but one, which used a before-after design, were randomised controlled trials. Study quality tended medium to high in the critical appraisal scoring system, but an overall low quality on the Jadad score for randomisation; with only one study from 11 scoring well on both these measures. Research into the use of video or DVD showed mainly positive effects on compliance; however, methodological issues limit clinical applicability.

CONCLUSIONS

Future well-designed randomised controlled trials with adequate sample sizes and reliable outcome measures will provide clearer evidence into the effectiveness of this technology in improving home exercise or health programme compliance, particularly for rural and remote populations.

Indicators of adherence to physiotherapy attendance among Saudi female patients with mechanical low back pain: a clinical audit

Background

Among current musculoskeletal interventions used to treat low back pain (LBP), physiotherapy exercise has the highest evidence of effectiveness in avoiding recurrence and chronic disability. However, effectiveness of physiotherapy is thought to be directly related to the patients' adherence to physiotherapy. Since adherence is reported to be directly influenced by socio-cultural factors, this study was conducted to investigate factors related to patients' adherence in a group of Saudi female patients with LBP.

Methods

A retrospective chart review was conducted on female LBP patients referred to the department of physiotherapy at a local tertiary hospital over a 12 month period. A total of 98 charts were reviewed. Two physiotherapists specialized in musculoskeletal rehabilitation collected information from the medical files. Data were classified in three categories: patients' personal demographics, patients' medical condition and history, and type of physiotherapy administered. Contingency tables and chi-square test were computed to test for differences in proportions. Spearman rank correlation coefficient was calculated to examine relationships among variables.

Results

Subjects who attended their scheduled appointments were classified as adherent (40%), and those who failed to attend 2 consecutive scheduled appointments and got discharged were classified as non-adherent (60%). Factors that significantly correlated with adherence included: age (r = 0.7, p < 0.05), initial pain intensity (r = 0.5, p < 0.05), and subjective report of improvement (r = 0.7, p < 0.01). Adherence did not correlate with the type of LBP, patient occupation, experience or nationality of the physiotherapist.

Conclusion

This study reveals an alarming level of non-adherence to physiotherapy among patients with LBP. It remains unclear as to what level of adherence is required to achieve beneficial effect of treatment. It is quite evident however, that early withdrawal from treatment would not allow the therapeutic benefits of the treatment to be realized. Future research should be directed toward developing strategies to improve adherence.