Journal of Physical Medicine

Patient Compliance with Physical Therapy Getting with the Program

Getting patients to participate actively in their medical care is something we all strive for as health care professionals. As a practicing physical therapist, getting patients to actively partake in the Physical Therapy (PT) process is no different. One of the fundamental concepts for PT treatment to work is that the patient must do their part. Keeping up with the prescribed exercises during and after PT is oftentimes necessary to promote gains with pain and mobility. Yet, we have all had patients that struggle to do their part before, during, and after PT. Is such noncompliance a fact of life or is there something we can do to better promote participation with PT?

Improving compliance with PT is potentially beneficial to the patients' health, but it may also reduce overall costs to the patient [1]. Low back pain is a common patient diagnosis treated by PT. A patient can develop low back pain as a short-term acute episode, as a stubborn, recurring condition, or as a lifelong, chronic impairment. As such, the medical costs associated with this common condition can be high for both the patient and the health care system. Research has demonstrated that if a patient with low back pain can adhere to a treatment program, there was decreased need to seek medical care (reduced healthcare utilization) and healthcare savings for the patient [1]. The reduced need to seek medical care has subsequently been shown to reduce the load on the healthcare system.

If compliance with a PT program carries the potential benefit of reducing costs, improving pain, function, mobility, strength, and overall quality of life, one would think the "proof would be in the pudding," so to speak. There are barriers to treatment however that keep a patient from ever getting a taste of success. Simple memory issues have been shown to account for adherence to medical advice [2]. These limitations may not be attributed to formal memory deficit-specific conditions such as Alzheimer's. Lack of memory retention may not actually be the patient's fault, but in actuality, the blame may lay on the clinician's shoulders. Targeting the patient with information that is too technical and not in lay terminology can lead to "information overload" and reduce the retention of the matter being discussed [3]. Even if well intended, if a patient is "over-educated" and overwhelmed with lots of terminology, compliance with advice has been shown to be reduced. On the flip side to this, under-educating patients as to why treatment is needed and failing to help patients make a connection between their treatment and their problems can negatively impact compliance. As a clinician, trying to strive for the middle ground of patient education may indeed improve patient memory of advice.

Even if a therapist can get their patient to ride their proverbial horse to the water, they still may not be able to get them drink. There are other barriers besides memory that can impair compliance. These barriers can both real and can be perceived [3]. Real barriers tend to be physical such as lack of equipment, lack of space, or transportation to and from appointments. Perceived barriers may or may not actually exist depending on a patient's perspective. Such things may include lack of time, anticipation of pain, or thoughts that a condition may never improve [3]. With this in mind, a therapist may need to dedicate more time helping a patient overcome such barriers. Anecdotally, these barriers may involve helping sedentary patients establish an exercises routine when they perceive to have lack of time or space. It may involve creating exercises that are appropriate for a patient that does not have equipment. Other tools to overcome such barriers may involve a moderate amount of education about pain that may or may not be associated with the prescribed exercise. Having a frank dialogue regarding what exactly is the expected outcome from doing PT is yet another tool to reduce the perceived sense of helplessness. This may include reviewing what the goals of given exercises or interventions are and frequently measuring and assessing markers of progress.

A barrier that has been shown to impair compliance and can be both physical and perceived is confidence, or lack of positive feedback [3]. Confidence feeds compliance. Not every patient can make the connection between range of motion gains and an improving rotator cuff. Nor the benefits of strength gains with a degenerative tendon. Nor the progress of reduced frequency of symptoms with chronic low back pain. When a therapist sees these things on a regular basis, they can become routine and implicit. Sometimes these implicit gains with a patient need to be made explicit or at the very least, made known. If a patient previously struggled with the technique of an exercise and is now doing it correctly - let them know of this progress. If a patient's motion, strength, mobility, balance or control is getting better - keep them in the loop. Every session does not need to be a pep rally, but if such positive feedback has been clinically shown to improve compliance, than it should be considered an important part of our patient interaction, treatment, and total process. Other studies have reinforced this concept by showing that motivating compliance/participation improves attendance to appointments and reduces pain and disability levels [4].

A home exercise program (HEP) is an integral component to most any PT intervention. Many PT's would argue that a HEP is the keystone of a patient's recovery. In order for positive changes to be made on impaired, injured or compromised soft tissue structures of the body, a HEP is often needed. Only performing exercises once or twice a week at a clinic is often not enough to impose such necessary changes. All programs, however, are not created equal. In regard to compliance, there are variables that make patients more likely to "take the bait" and actually do their HEP. With regards to number of exercises issued - more is not necessarily better. Patients of both genders seem to perform better given fewer exercises vs many [5]. Patients trend towards better compliance given a max of 1-2 exercises. Once HEP's exceed 5-8 exercises, compliance was shown to be reduced5. This may be attributed to the perceived barriers aforementioned above. If patients have constraints such as time, 1-2 exercises is much more conducive than 5-8, regardless of how appropriate these 5-8 exercises might be for a patient's condition. This puts inherently more pressure on the therapist to find the most important and appropriate exercises to address the specific needs of the patient. With an exercise cap at 1-2 exercises, this also means that as a patient progresses or changes their status, their HEP needs to change accordingly. With this in mind, compliance should improve if a HEP is a constantly evolving entity instead a fixed treatment from start to finish.

If less is more, then participation in a prescribed HEP should be straight forward, provided only 1-2 exercises are given. However, it is not this simple. The way in which exercises are instructed is yet another variable affecting program compliance. Not all exercise instructions carry the same face value. Video instruction has been shown to improve compliance with recommended exercises and symptom management techniques in patients with low back pain [6]. As such, providing a patient with resources that allow them watch videos on proper exercise technique and rationale is more than appropriate. In the age of smart phones, this has never been easier. Many exercise software kits provide direct links to sites that show video instruction on exercises, ergonomics, transfers, and symptom management strategies.

If a patient cannot watch videos on exercise and treatment strategies, it appears as though a patient leaving their appointment with something in their hand does indeed improve compliance. Even if a patient is thoroughly instructed on their 1-2 home exercises, and a stellar job is done verbalizing these instructions, it is always best to give something in writing. Written instructions seem to carry another layer of reinforcement to help improve compliance [7]. This additional education strategy gives patients a reference when learning something that is oftentimes quite difficult to remember and perform. For example, if a patient cannot get a certain muscle group to contract in order to move better, written instructions serve as a tool to learn this new strategy. If a patient has poor understanding of anatomy, compensation with movements, or minimal experience with exercise, a written reference may make all the difference in the world clarifying something relatively foreign. Even if a patient has thorough exercise understanding and has fantastic technique, having something physical to look at can serve as a visual reminder to help build compliance.

While most practicing clinicians do want to see their patients get better, sometimes the best medicine is not their own. Exposing patients to activities that can improve their status outside of PT may be the road best traveled for some patients. Compliance with some specific activities other than PT has been shown to reduce pain and improve function. For example, Yoga has been shown with some studies to improve low back pain and mobility as effectively as some PT interventions [8]. Research studies have also demonstrated the benefits of some activities such as Tai Chi for improving balance and muscle tone. While these activities may not be immediately appropriate for everyone, directing patients towards these activities may be more beneficial to routine compliance and overall recovery. Maintaining some knowledge regarding alternative and adjunct treatment options such as massage, injections, and acupuncture can help guide a patient in the right direction.

Compliance with treatment can help patients recover from injury, reduce healthcare costs, and help prevent future injuries. Selling a patient on their treatment is complex and is not a cookie cutter-one size fits all approach. Some patients may need more instruction, some may need audio-visual technologies, while others may need help establishing a daily routine. If you can build short term compliance however, a patient can begin to see the benefits of their care. This may allow them to be able to take the next step towards independence and self-regulation [9]. Instilling a lasting impression of your treatment with your patient will help them to build a routine. If you can show someone how to help themselves, then you help provide benefits indefinitely.

References

1. Hanney W, Masaracchio M, Xinliang L, et al. (2016) The influence of physical therapy guideline adherence on healthcare utilization and costs among patients with low back pain: A systematic review of literature. PLoS One 11: e0156799. 
2. Ice R (1985) Long term compliance.  Phys Ther 65: 1832-1839.
3. EM Sluijs, GJ Kok, J van der Zee (1993) Correlates of exercise compliance in physical therapy. Phys Ther 73: 771-782.
4. M Friedrich, G Gittler, Y Halberstadt, et al. (1998) Combined exercise and motivation program: Effect on the compliance and level of disability of patients with chronic low back pain: A randomized controlled trial.  Arch Phys Med Rehabil 79: 475-487.
5. KD Henry, C Rosemond, LB Eckert (1999) Effect of number of home exercises on compliance and performance in adults over 65 years of age.  Phys Ther 79: 270-277.
6. Neusa Maria CA, Margareta N, Rudi Hiebert, et al. (2002) Predictors of compliance with short-term treatment among patients with back pain.  Rev Panam Salud Publica 12: 86-95.
7. Schneiders A, Zusman M, Grad Dip Manip, et al. (1998) Exercise compliance in acute low back pain patients.  Manual Therapy 3: 147-152.
8. Saper R, Lemaster C, Anthony D, et al.  (2017) Yoga, physical therapy, or education for chronic low back pain. Ann Intern Med 167: 85-94.
9. Sluijs E, Knibb JJ (1991) Patient compliance with exercise: Different theoretical approaches to short-term and long-term compliance. Patient Educ Couns 17: 191-204.