Robert M. Smith, D.C., DACRB
Key Learning Points:
- Compliance with home exercises is poor
- Knowledge of the patient’s exercise history is important
- The patient’s lifestyle and prognosis should guide prescription
- Doctor-Patient relationship can improve compliance
- Number, type and format of exercises influences motivation
Objectives: The vast majority of Doctors of Chiropractic (D.C.) use both in-office and at-home rehabilitation programs with their patients. The hypothesis is that many doctors have difficulty getting some patients to comply with their prescribed exercise programs. There is very little chiropractic literature regarding exercise compliance. The purpose of this study was to summarize current research on motivational strategies for improving patient compliance with prescribed exercise plans.
Methods: Searches were performed of online journal databases which did not require a subscription using keywords such as “exercise (compliance)”, “(non-)compliance”, “adherence”, “behavioral interventions”, “exercise (non)adherence”, “exercise motivation”, “home exercise program (compliance)”, “drop-out (research)” and “improving exercise compliance”. Articles were grouped according to type of strategy used (intrinsic or extrinsic), patient characteristics or condition, patient relationships and exercise prescription format.
Results: Only one article addressing this topic was found in the chiropractic literature, and this was used as a platform on which to add additional findings. No articles were found which summarized the variety of strategies addressed in the literature. A wide range of sources addressed this topic in limited ways, and these sources were organized in hopes of providing a basis for future study. A checklist was developed to summarize the best strategies.
Conclusions: A provider who gathers appropriate information regarding the patient’s exercise history and lifestyle, develops an exercise plan with the patient to improve symptoms, limitations or prognosis, and prescribes an appropriate amount and difficulty level of exercise with adequate descriptions and follow up, will improve the chances of success.
Key Indexing Terms: Physical Exercise, Patient Compliance, Rehabilitation, Motivation
This article will focus on a basic question that Doctors of Chiropractic deal with on a daily basis: How can I motivate my patients to comply with their exercise plan? Chiropractors, especially those specializing in rehabilitation, confront a common scenario with patients: Time is spent during the initial visits analyzing a new patient’s weaknesses, asymmetries, deficiencies and tendencies as they relate to the presenting problem. An exercise or series of exercises is developed to address these deficiencies, and the chiropractor spends time demonstrating and reviewing these exercises with the patient. On proceeding visits, the patient is questioned as to how the exercises are going at home, how often they are being performed, and if any problems were encountered. Typical responses indicate that the patient has been too busy to practice, has forgotten, or simply didn’t do the exercises. During review of the exercises, the patient makes gross errors or is unable to recall exactly how to do them. The chiropractor gets frustrated as this interaction is repeated over several visits and precious time with other patients is lost. Eventually, doctor and patient may give up: the patient may discontinue care and seek other avenues of treatment, or the doctor may release the patient, refer the patient elsewhere for care, or simply continue satisfying the patient’s desire for passive care.
For the Doctor of Chiropractic, years of learned and applied knowledge and expertise in rehabilitation procedures are useless if the patient does not comply. However, there is a paucity of chiropractic literature on the subject of improving compliance. There is one article in the chiropractic literature which specifically addresses this topic; almost all noted references are found in the physical therapy literature. Even the Chiropractic Rehabilitation Diplomate program does not provide formal training in the area of compliance, although Leibenson’s second edition text does include a chapter on “Active Self-Care”, which incorporates a section on “Motivation Issues”1. The purpose of this literature review is to consolidate and categorize documented motivational strategies that can be used by the busy clinician to improve compliance.
Between 96 and 98% of chiropractors provide exercise advice or instruction to their patients2-3. However, studies estimating and defining compliance vary greatly, but generally show that long-term patient compliance with home exercises is poor, ranging from approximately 25-75%4-10. This impacts the effectiveness of care by extending the duration of symptoms or slowing the rate of healing and progress. It is well-known and even assumed by the practitioner that compliance is poor, but many chiropractors lack the knowledge of how to improve compliance.
Most often, exercise instruction is in a format that can be performed at home, instead of in-office rehab2-3. It is not economically feasible for most chiropractors to implement a full in-office rehab program due to limitations of time, insurance reimbursement, space or staffing. Most chiropractic offices are not set up to handle high volumes of rehab patients, because time is dedicated to other procedures such as evaluations, modalities or manipulation. Supervising therapeutic exercise is also a very time-intensive procedure and sometimes does not provide adequate reimbursement under many insurance plans. Rehab requires additional space, especially for high volumes, and most chiropractors have a majority of their office space dedicated to exam, treatment and administrative tasks. If a chiropractor does have adequate time and space to handle high volumes of rehabilitation patients, extra staff will be required to assist in patient flow and supervision. These obstacles make supervised home exercise programs a valid compromise solution. It is noted that “…supervision of exercising is also a very time-intensive and expensive form of treatment. In these days of cost-awareness and health price competition chiropractors need to do everything possible to minimize the costs of such supervision, while still making sure that the time spent in designing an active program is not wasted. This balance of supervision and cost-effectiveness can be best achieved by regular monitoring of home exercise programs.”11 For patients with ankle sprains, these results have been confirmed in a small randomized controlled trial.12
Compliance strategies can be divided into two basic groups: Intrinsic motivators and extrinsic motivators13. Intrinsic motivators are characteristics within the patient that would inhibit or enhance the patient’s desire to exercise. Based on a review of the literature on exercise compliance, sub-groups were created: patient characteristics and patient condition. (See Table 1) Intrinsic motivators can include patient characteristics such as attitude toward exercise, feelings of self-efficacy, chronological age, home life, and willingness to incorporate exercise into daily life. Other intrinsic motivators focus on the type of condition the patient suffers from, its severity and prognosis, and the level of disability and limitation it places on everyday life.
Extrinsic motivators are conditions existing outside of the patient which influence his or her desire to exercise. Extrinsic motivators include the basic groupings of Doctor-Patient relationship, social relationships, and presentation format. (See Table 1) The Doctor-Patient relationship can influence the patient’s loyalty to the doctor, his perception of barriers to improvement and his desire for feedback. The patient’s other social relationships can modify his enjoyment of home exercise and perception of social supports in the process of getting better. Finally, the way exercises are presented to the patient can have a large impact on his continuing level of motivation. Instructions can be given in any number of formats and follow-up strategies can be targeted to provide the proper balance of independence and doctor-driven motivation.
|Intrinsic Motivators||Extrinsic Motivators|
• Exercise History
• Doctor-Patient Relationship
• Severity and Prognosis
INTRINSIC MOTIVATORS: PATIENT CHARACTERISTICS
Patient characteristics should be taken into account when designing a rehab plan, which may lead to improved compliance. Although beyond the scope of this paper, it may be possible in the future to prescreen patients and identify characteristics that will improve compliance to rehabilitation programs. Two pilot studies have investigated the use of a short intake questionnaire or “exercise motivation index” to prescreen potential exercise compliance levels.14-15 During the initial visits with the new patient, it is important to gain insight into the patient’s history of exercise involvement and rehabilitation from prior injuries, and how the patient felt about those experiences. The uniqueness of each patient will affect their ability and willingness to comply. In general, patients who have more positive exercise experiences and a belief in the benefits of exercise will have better compliance14, 16-17. Reinforcement of the idea that exercise is critical to improvement should occur on each visit.
Self-Efficacy & Exercise Beliefs
Patients who have a sense of self-efficacy, a positive attitude and belief in the benefits of exercise will more likely comply with rehab assignments.14; 17-18 There are several practical ways to determine a patient’s level of self-efficacy in a busy office setting. The use of a “yellow flags” form filled out by the patient, or a yellow flags checklist evaluated by the doctor19, can provide advance warning to the practitioner of potential compliance problems. In addition, being alert to any comments a patient makes regarding “Fear Avoidance Beliefs”20 can help the doctor focus on reinforcing the importance of rehabilitation and consistently providing motivation before non-compliance becomes a hindrance to care.
Age and Lifestyle
In developing a supervised home exercise plan for our patients, chiropractors should take into account their age and home life. In general, research indicates that patients who are younger will have lower levels of compliance.21-22 Younger patients may tend to place a lower priority on exercise as a means of healing, or may simply be engaged in too many other activities (education, social activities, career advancement, childcare) to be able to accommodate exercise. Similarly, patients who have children at home will have more difficulty adhering to a home exercise plan.21 In taking a history of the patient and inquiring about their lifestyle and ADLs, it is common for patients to relate how busy they are or how they lack sufficient time to accomplish their daily tasks. In one study, among patients who are non-compliant with exercise, 80% cited “lack of time” or “too busy” as key reasons.23 “It is suggested that particularly for middle-aged individuals, insistence on medically supervised exercise prescription and programming offers an unnecessary barrier to exercise adoption and compliance.”24 Accounting for the patient’s commute, job demands and family & home responsibilities should be a key component in developing their supervised home exercise plans.
Accommodating Exercise and Treatment Value
Having knowledge of the patient’s outlook regarding treatment is also important. Again, referencing “Yellow Flags”, does the patient tend to have a “passive” mindset regarding treatment? Does she seem willing to accommodate exercise into her ADLs? Patients who place a priority on having a set schedule of exercise will have a better level of compliance than those who have no routine.16 Patients who continue to comply with exercises have a greater willingness and ability to accommodate exercises within everyday life.25 A study of patient compliance with individualized rehabilitation programs revealed that those who exercised once a week or less often valued the significance of healthcare treatment less.22 It is important in developing a rehab plan with a patient to consider the priority they are placing on treatment and specifically, exercise.
INTRINSIC MOTIVATORS: PATIENT CONDITION
Severity and Prognosis
When designing a rehab program for a new patient, it is critically important for the practitioner to understand the severity of the condition, as well as understand the patient’s perception of their own condition and its severity. A number of intake forms are widely available and allow the chiropractor to understand the patient’s perceived severity of symptoms, which will influence the patient’s reasoning for continued compliance.25 The use of an Oswestry Disability Index, Neck Disability index or Quadruple Visual Analog scale allows comparison between the practitioner’s and patient’s perception of the condition. A study of adults diagnosed with arthritis found that severity of disease differentiated exercisers from non-exercisers.17 Another research article summarized it best, “Results also showed that those who exercised once a week or less often valued the significance of healthcare treatment less, perceived higher pain intensity, presented a higher Oswestry score, worse general health (and) more pain locations”.22
In addition to the severity of the condition, the prognosis is also a determining factor for exercise compliance. Simply put, “a bad prognosis is negatively related to compliance”.26 This may be because the patient feels a degree of helplessness in the face of a chronic disease, or feels distressed about the lack of an available cure. When presenting the diagnosis and prognosis to the patient, it is important to focus the patient on the importance of rehabilitation as a means of ongoing management. The chiropractor can provide support by encouraging exercise to prevent relapses or exacerbations.
Rehabilitative exercises can help not only in the prevention of relapses, but can also provide short-term symptom relief. For example, chiropractic patients with radiculopathies can quickly learn the value of Mackenzie-based exercises in alleviating extremity pain. This ability to quickly relieve pain becomes a motivator in and of itself. Research with elderly patients experiencing chronic lower back pain found that “the most frequently stated reasons for nonadherence was that exercise did not help or aggravated pain”.27 Conversely, 80% of these patients who continued regular exercise cited the health benefits they received. Yet another experimental trial found similar results: 75% of those who continued exercise referenced “symptom relief” or “feel better” as reasons.23 A necessary precondition for continued compliance includes the patient’s perception that the exercise ameliorates unpleasant symptoms.25 When designing the home exercise plan it is wise to include, whenever possible, exercises that will relieve the patient’s symptoms. This will increase the likelihood of compliance with the plan.
A final intrinsic motivator related to the patient’s condition is the impact it has on their ADLs. Patients who are very limited in daily functioning will have a harder time complying with exercise instructions. Activity limitations function as a barrier to self-care, so it is important for the chiropractic rehabilitation specialist to account for these limitations when giving instructions.18, 26, 28 The home exercise plan must strike a delicate balance between working within the patient’s limitations, while at the same time improving that limitation. Take, for example, a patient who has increased lower back pain with lumbar flexion but also has abdominal weakness. Starting the patient with hook-lying pelvic tilt exercises or prone half-planks would be preferable to starting them on abdominal crunches. Compliance should improve by working within the patient’s limitations.
Getting to know the patient is a key to developing an appropriate home exercise plan. From intake through reevaluation, the chiropractor must gain insight into the patient’s exercise beliefs, exercise history, lifestyle and the value they place on exercise and treatment. Taking into account her diagnosis, the severity of her condition, what makes it better or worse and how badly it limits ADLs will provide a higher likelihood of compliance. The chiropractic rehabilitation specialist who develops this knowledge will have a better understanding of how to specifically provide motivation to the patient.
EXTRINSIC MOTIVATORS: RELATIONSHIPS
Just as accurate understanding of the patient improves compliance, so the Doctor-Patient relationship can also influence compliance. Setting goals together, establishing a bond of trust and loyalty, and providing positive feedback will set the tone for your continued work together. Meshing patient and doctor goals shows promise as a means of improving compliance.29 A study of the effect of treatment goals on compliance lead to the conclusion that “collaboratively set goals appear to lead to a higher level of treatment compliance than physiotherapist-mandated goals.30 Loyalty to the practitioner initially produces higher compliance, emphasizing that establishing a close relationship helps.25 Does the treatment plan include praise for success in achieving the goals you set together? An important factor related to noncompliance was a lack of positive feedback.26 The doctor-patient relationship is so important that it can drive a patient to the opposite of compliance. A study of compliance with medication dosages among elderly Japanese found that intentional noncompliance was the strongest predictor for poor compliance, which was influenced by the relationship between the patient and the physician.31 It is critical for the chiropractor to earn the patient’s respect and trust, set goals together with the patient, and praise progress when it occurs.
Patients who receive support at home will also improve their chances of complying with home exercise plans. A review of three studies in the psychology field found that it is possible to predict an individual’s intention to exercise by the “extent to which individuals perceive that significant others encourage choice and participation in decision-making, provide a meaningful rationale, minimize pressure, and acknowledge the individual’s feelings and perspectives.”32 Another study of exercise among elderly knee osteoarthritis patients found that among those who exercised regularly, social support was important for companionship, making friends and exercising with others who had similar problems.16 The doctor should be aware of social supports at home and encourage the patient to make their family and close friends aware of their condition and the expectations of exercise. This will provide the patient with encouragement and accountability.
EXTRINSIC MOTIVATORS: EXERCISE FORMAT
On a more practical level, the format in which the exercise prescription is given can influence the patient’s level of compliance. This is the area in which the chiropractor has perhaps the greatest amount of control. The way in which goals are set, the number of exercises given, the types of materials used to explain them, and the type of follow up can all be controlled to provide a better chance of patient follow through, and thus a better potential outcome.
Goal-setting is an often overlooked element in the exercise prescription. The patient and doctor need to agree on what is to be expected and this needs to be clearly outlined. This provides the patient with a target to aim for, as well as a means for the doctor to track progress and improvement. A discussion on the importance of collaborative goal-setting has already been included.30 This area holds promise as a means of improving physical activity behavior.29
Goal-setting works particularly well when the patient is in pain1, which is when patients are most open to any avenue of relief and are willing to do what it takes to reduce their own suffering. This is likely why short-term compliance is typically higher than long-term compliance. The addition of some motivational strategies during this “window of opportunity” may be helpful. A double-blind prospective randomized controlled trial comparing an exercise program with a combined exercise and motivation program (using five compliance-enhancing interventions) found that “the combined exercise and motivation program increased the rate of attendance at scheduled physical therapy sessions, i.e., short-term compliance, and reduced disability and pain levels by the 12-month follow-up. However, there was no difference between the motivation and control groups with regard to long-term exercise compliance.33 Thus, motivation strategies used by the doctor during the initial visits can prove helpful in supplementing treatment with home exercise.
Number of Exercises & Visits
When selecting exercises, the chiropractic rehabilitation specialist should focus only on the most important deficiencies or movements they want to accomplish with the patient. Giving too many exercises, too soon, may discourage or confuse the patient. This is an obvious but important reminder. Among elderly subjects, those who were prescribed 2 exercises performed better than subjects who were prescribed 8 exercises. 34 As the chiropractor sees the patient achieve mastery of the home plan and the patient finds the exercises helpful, additional exercises can be added or the current exercises can be made incrementally more difficult. “It is important to keep the less fearful patient sufficiently challenged to avoid boring the patient while at the same time being sure they are performing exercises with the necessary control to isolate the ‘deep’ stabilizer muscles.”1 Once the provider and patient are satisfied that the patient is ready to progress, new exercises and challenges can be added to the home program.
To reinforce performance of the exercises, they should be reviewed periodically. “The high rates of relapse that tend to occur after short-term behavioral interventions indicate the need for maintenance programs that promote long-term adherence to new behavior patterns”.35 A trial of older adult in-patients showed that they did not remember physiotherapy exercises effectively after a single teaching session.36 Although it is not necessary to see the patient multiple times a week to review, it is helpful to add a small number of additional visits to review and supervise the exercises.37 It is also helpful to the patient to periodically review the home exercise plan in order to emphasize its importance, provide accountability and ensure that the exercises remain challenging. A number of other studies reinforce this point; several reinforce the conclusion that the “supplementation of a home-based exercise program with a class-based exercise program led to clinically significant superior improvement”38, and was “more effective than home exercise alone”39, also 40. These improvements were still evident at 12-month review.
What is the best way to present the exercises to the patient? There are multiple learning styles, so the best approach will most likely utilize a variety of measures. Obviously, once the doctor has described the exercise and why it is being prescribed, the patient should perform the exercise with direct supervision. Is it helpful to send the patient home with instructions? A study comparing patients who received verbal and written instruction with patients who received only verbal instruction concluded, “Patients receiving additional written and illustrated instruction had a significantly higher mean compliance (77.4%) compared to the group who received verbal instruction alone (38.1%).41 This is a significant difference and reinforces the importance of sending the patient home with written instructions. Brochures, when combined with verbal instruction, can be as effective as audio or video instructions to enhance correct performance of exercises.42 There are a number of vendors or rehabilitation software programs available to accomplish this.
However, the doctor should not depend entirely on an exercise handout or brochure to achieve compliance. Continued follow up and review is important. Elderly in-patients were not found to remember exercises effectively after a single teaching session and an exercise handout did not significantly improve their memory.36 Additional visits to review the home exercise plan are helpful and can provide greater symptomatic relief.37 And when exercises are difficult for the patient to perform, “audiotapes and videotapes may provide additional cues to maintain correctness of performance.”42
Internet & Telephone Interventions
In addition to in-office follow-up, doctors can try making use of other means of intervention. Research is beginning into “innovative and time-efficient alternatives to face to face contact with healthcare providers”.35 Can chiropractors utilize their administrative staff or the internet to follow up with patients in an effective manner, freeing up time to focus on care in the office? One systematic review of the literature indicates that this is possible, finding that in 69% of physical activity studies, positive outcomes were reported using the telephone as the primary intervention method43. Follow-up for 6 to 12 months and 12 or more calls produced the most favorable outcome. In another study, 511 women were mailed six sets of computer-tailored health messages and received two computer-tailored telephone counseling sessions. Intervention participants were more likely to move forward into more advanced stages of physical activity change than the control group.35 In practice, this could be accomplished by having one’s chiropractic assistant call patients briefly every month to provide accountability or review exercises verbally.
More recent research is delving into the use of internet-based physical activity interventions. This has been defined as an exchange of information via the internet between a health care provider and a patient, or the use of email for communication between a health care professional and a patient.44 There is significant evidence that website-delivered or internet-based physical activity interventions are superior to a print-based intervention, waiting list strategy or other non-Web-based intervention.44-46 A 2007 review of the literature found that better outcomes resulted when email or website interventions had more than five contacts with participants and when the time to follow-up was short (less than three months).45 Many chiropractors already utilize e-newsletters to communicate health messages to patients, making this an easy strategy to incorporate into practice. Early studies are promising but are limited by small sample sizes and unclear identification of internet strategies that improve compliance.
This article has provided a review of successful motivational strategies to improve patient compliance with home exercise plans. Almost all chiropractors utilize exercise advice or instruction in the care of their patients. This is most easily done in the form of a supervised home exercise program. Because accountability and contact with the patient are limited, compliance with this instruction is generally poor and limits the effectiveness of treatment. However, knowledge of effective motivational strategies can improve the patient’s compliance and the outcomes of care. Patients can be motivated internally or externally, and research has outlined many strategies that the practicing chiropractic rehabilitation specialist can use to tap this drive. It would be helpful to use a checklist (see Table 2) to ensure that these strategies are being used.
Table 2: Rehab Checklist
___ 1. Does the patient have a history of successful rehabilitation of a prior injury?
___ 2. Has the patient regularly exercised at some point in the past?
___ 3. What is the patient’s belief regarding the necessity or usefulness of exercise in
___ 4. Is the patient’s lifestyle conducive to incorporating exercise?
___ 5. Will my exercise plan alleviate symptoms or help the patient overcome ADL limitations?
___ 6. Will my exercise plan improve the patient’s prognosis?
___ 7. Have I established a relationship of trust and collaboration with the patient?
___ 8. Does the patient have a support network to encourage home exercise?
___ 9. Did exercise goals include patient input?
___ 10. Is the number of exercises given appropriate and challenging for the patient?
___ 11. Have I given the patient materials describing the exercises and do I plan on following
up to review them with the patient?
During new patient intake, the chiropractor can use knowledge of the patient’s exercise history, exercise beliefs, age, lifestyle and value the patient places on treatment to formulate a plan for home exercises. Once the diagnosis is made and treatment is initiated, taking into account the severity of the condition, how it limits the patient’s ADLs, the prognosis and what alleviates the symptoms will lay the groundwork for a successful treatment regimen.
When introducing the exercise plan to the patient, the chiropractor should ensure that he is collaborating effectively with a trusting patient by setting goals together. The patient can consider bringing a workout partner or family member along to a visit to provide support and accountability. The initial rehabilitation plan should be limited in scope to avoid overwhelming the patient or aggravating the patient’s condition, but regularly reviewed and updated to challenge the patient and foster progress. The chiropractor should provide printed take-home materials for the patient to use as a reminder, and can consider using his website as a platform for the patient to review or update exercises. It may also be feasible to use email as a means of communication regarding the home exercise plan.
There is much research to be done in the area of chiropractic exercise compliance. The chiropractic rehabilitation diplomate program fits in well with the overall trend in healthcare toward patient-centered care. This paper attempts to move the research base forward by summarizing current research and categorizing known motivational strategies. The ability to further motivate patients using proven and innovative strategies will enhance our standing in the healthcare community and improve our patient’s lives.
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Robert M. Smith, D.C., DACRB
Private Practice of Chiropractic, Easton, PA, USA
3413 Sullivan Trail
Easton, PA 18040