HEP adherence for neck and LBP


While I have an outpatient that suffers from something other than back or neck pain, I found this intellectually stimulating as it is about the different aspects of adherence. What makes a patient do all the exercises in a HEP? Why do they do all the repetitions you prescribe? And what about the prescribed number of times per week? What should you consider as you develop a HEP for a patient? (note: this article is not specific to geriatric populations).

Medina-Mirapeix F, Escolar-Reina P, Gascón-Cánovas JJ, Montilla-Herrador J, Jimeno-Serrano FJ, Collins SM. Predictive factors of adherence to frequency and duration components in home exercise programs for neck and low back pain: an observational study. BMC Musculoskeletal Disorders 2009, 10:155 doi:10.1186/1471-2474-10-155.
Why the study matters: Exercise has been shown to be a benefit to those with neck and back pain but adherence to a HEP is problematic with an estimate of 50% or less. Adherence can be impacted by socio-demographics, social support, motivation, illness, environment, the program itself, or the provider itself. Self-efficacy (SE) is a consistent predictor of adherence, whereas pain intensity has shown variability in predicting adherence. In healthy people there is evidence that determinants to the frequency of the HEP is different than the determinants of the duration of a HEP, but it is unknown if these differences are found in those in PT and performing a HEP for chronic neck and LBP.

Hypotheses: The researchers did not clearly delineate a hypothesis, but the purposes of the study were to determine whether patients with neck or low back pain have different rates of adherence to exercise components of frequency per week and duration per session when prescribed with a home exercise program, and to identify if adherence to both exercise components are predicted by distinct factors.”

Outcome measures: Mailed questionnaire “about the quality of clinical encounters with the [PT] during the intervention program, environmental factors and adherence behavior to [HEP] during the last week.” Predictive factors were measured before, during and after PT treatment. The questionnaire utilized a Likert scale (5=always to 1=never) for perceived barriers and emotional support, and an adapted version of a SE scale about the subjects confidence in performing the HEP. Patient satisfaction with clinical encounters was rated on a continuous scale (0-10) and the behavior of information-providing was rated yes/no (clarifying doubts, giving information about the condition, and justifying advice). Adherence was “measured as compliance to each prescribed component (frequency and duration) to the HEP (never, seldom, often, almost always, always). Adherence was then treated as dichotomous with adherent being always or almost always.

Subjects/ patients: Subjects were included if they had chronic (>3 months) of non-specific neck or LBP and received PT in primary care centers in Spain. Exclusion criteria included 70 yrs old, illiterate or unable to write, cognitive deficit (Alzheimers, dementia, etc), unable to attend all sessions of PT, or if the PT ordered a cessation of the HEP .
Intervention: This study was prospective, examining patient adherence one month after PT to assess short-term adherence to the HEP. The HEP was different for each patient but the PT recorded the type (strength, stretching), total number of exercises per session, days/week to be performed, and estimated duration each session should take.

Results: There were 317 possible subjects with 50 being excluded. Of the 267 eligible participants, 104 had neck pain and 163 had LBP. 250 (93.6%) participated in the interview at baseline and 184 (68.9%) returned the survey. Non-respondents did not differ significantly when compared by gender, location of pain, education level, sick leave, work participation, pain intensity, and pain disability. “However, the proportion of patients above 59 years is higher among respondents.”

Adherence rates: 70.1% were adherent to duration and 60.7% adherent to frequency.

Predictive factors for frequency were use of PT in the past, participation/ adherence to previous HEP, being given >6 exercises, environmental factors and SE, having doubts clarified, satisfaction for treatment and good adherence to duration.

Predictive factors for duration were participation and low adherence in another HEP, exercises fitting into daily routine, emotional support, SE, supervising exercises in the health care centers, and adherence to frequency.

What I would like to know more about: Apparently all patients receive four weeks of PT and are then d/c’ed – what drives that decision? Was adherence to strengthening compared to stretching? Wouldn’t excluding those who do not attend all PT sessions automatically skew your results, likely improving your adherence percentages to the HEP (34 of 317 excluded; additionally they only analyzed survey respondents and did agree that excluding non-respondents may have biased the results, but believed that intent-to-treat analysis would influence the analysis with non-adherence entered for those who did not respond)? One of the exclusion criteria is if the PT ordered them to not perform the HEP – since they received it upon d/c, how could that be an exclusion criteria (16 of 317 excluded)?

How this will affect my clinical practice: Working in a SNF with an outpatient clinic, I can’t really say this will affect my clinical practice as I don’t have anyone with back or neck pain at the moment. For my outpatients I do keep the number of exercises to 4-5 at the most, I encourage self-efficacy, instruct them on the purpose of the exercise, and help brainstorm how to incorporate them into a daily routine. However, regardless of setting I think that adherence should be considered – both how adherence is measured as well as how to improve it. I will be giving the guest lecture to the UW DPT students regarding adherence to exercise for older adults – if I come across any new nuggets I will post them.

Picture credit: Crick, originally uploaded by Martin Kingsley.


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