The 14 keys you need to know to promote adherence to exercise therapy
Increasing life expectancy and, with it, the number of people affected by chronic diseases, constitute a challenge for healthcare systems around the world. They have seen their costs rise to provide care for this type of profile.
Physical exercise 🏋️ is one of the most important interventions for this population group, being “the medicine 💊 we should all take regularly“. It is the mainstay for the prevention and treatment of a large number of diseases. Even knowing all this, inactivity and sedentary lifestyles are the predominant standard in the general population.
The WHO states that adults should get at least 150-300 minutes of aerobic physical exercise at a moderate intensity, or 75-150 minutes of vigorous activity per week, to achieve the expected health benefits. However, little is said about the fact that a large percentage of the population ends up dropping out of exercise, so that they do not benefit from it. Here it is essential to include strategies and tools that guarantee the patient’s commitment and involvement, and above all, their maintenance over time.
To assess what the evidence says today, Collado-Mateo D et al (2021) conducted a review of the literature, from which they obtained 14 important points to promote adherence to exercise, which we summarise below:
1. Design of the Exercise Programme
When considering an active work programme for the patient, three main factors should be taken into account: the individualisation and scientific basis of the type of exercise to be selected, and the duration of the programme during the week.
The use of exercises that are based on the latest scientific evidence (Reviews, Clinical Practice Guidelines, quality RCTs…) have been shown to increase adherence levels. In addition, we must individualise them in terms of type of exercise, intensity, duration or frequency, although without losing sight of the patient’s interests and needs. The duration of the session should be moderate, neither too long nor too short.
With regard to weekly frequency, it has been observed that exercise programmes of 1 session/week result in poorer outcomes in terms of engagement with therapy.
An example of an evidence-based exercise programme is the SARAH study published by Sarah Lamb et al. in the 2015 RCT for patients with rheumatoid arthritis involvement in hands. To develop the programme, the authors conducted a literature review, interviewed experts in the field, and carried out a pilot study.
After analysing the data obtained, they developed a specific exercise programme for the fingers, hands and upper limb affected by rheumatoid arthritis. This included seven mobility exercises and four strengthening exercises (see image below). The work was performed daily for 12 weeks.
One of the strengths of the study was its capacity for individualisation thanks to a simple questionnaire such as the Modified Borg Fatigue scale, adapted to 10 points. This scale allows a easy self-perception of effort, for self-dosification. Thus, to ensure patient safety, it was proposed that patients should not exceed a moderate level of fatigue (3-4 out of 10).
Here you can see more specifically what the dosage of the programme consisted of, and what the initial sets and repetitions of the exercises were:
This, together with other adherence-promoting strategies (such as exercise diaries, which will be discussed later), achieved more than significant effects on function, pain and cost-effectiveness, compared to the control group.
2. Multidisciplinary Team
Several scientific publications have shown how the involvement of a greater number of professionals from different specialities can improve adherence to treatment. Psychologists, doctors, physiotherapists, occupational therapists, nurses… all can contribute to the common goal.
An example could be Behavioural Change techniques or Cognitive-Behavioural Programs to achieve changes in the patient’s routine, where psychologists will play an indispensable role. The patient must become aware of his or her problem and find a solution.
3. Supervision during the Exercise sessions
It is essential that the patient perceives that they are being monitored and controlled by their therapist. This supervision should include constant feedback, support and motivational messages to increase their confidence and self-efficacy with pain.
It does not mean that the sessions have to be face-to-face. An exercise programme can also be supervised telematically. Moreover, this second option gives the patient much more flexibility to choose when to do it, and to adapt it to his or her daily routine, which will further encourage adherence.
Did you know that ReHand App allows Telematic Monitoring thanks to its Reporting System?😯
4. Use of New Technologies
We have all experienced in recent months the enormous evolution of Digital Health and m-Health within the healthcare field. Video call platforms, apps, digital tools, wearables… all of them allow something as important as monitoring adherence to treatment, the frequency of exercise (when, how much and how), providing instructions or prescribing exercise programs.
Within the wrist-hand-finger segment, we find ReHand digital platform. ReHand is a tool for us, the healthcare professionals, that enable us to:
- To Prescribe a therapeutic exercise program to our patient according to his or her pathology.
- To give our patient access to the tablet app to be treated with his prescribed program.
- To receive weekly information on treatment adherence and progress.
5. Initial Evaluation of our Patients
In a first session with the patient, we must assess the patient’s own characteristics. Such as their state of health, their lifestyle or their socio-economic status, in order to find out the possible barriers and facilitators to the execution of the exercise program.
The presence of chronic diseases, pain, fatigue or depression have been negatively related to the patient’s commitment to exercise. Other negative factors associated with adherence are pre-session lifestyles such as sedentary lifestyles, smoking or alcohol abuse.
6. Educational Strategies
An important point during exercise prescription is to explain the benefits of exercise to the patient and to provide reassurance. Many patients continue to see exercise as counterproductive, which can make their pain worse. We must talk about the neuroscience of pain, and outline possible short and long term expectations.
Examples such as “exercise with a little discomfort is not bad” or “pain does not equal harm” are concepts that we must explain to ensure adherence to the program we have delivered.
Not sure how to include information on Neuroscience and Pain in your treatment?
Don’t worry! Here is some material you may find useful:
–Material about Chronic Pain from the University of British Columbia: they developed this interactive material to address in a super simple way something as complex as Chronic Pain. They include the neurophysiological basis, adaptive and maladaptive responses to pain, and some subtypes of pain, so take a look because it is really worth it!
–Audiovisual material, interview model and more references!! Pain in Motion is a group of international researchers and clinicians who seek to gain an in-depth understanding of the biopsychosocial model of pain, to have a direct impact on the population and to bring about changes in health policies. To this end, they have developed accessible and translated material for health professionals. Believe me, you can get a lot out of it!
7. Pleasant and Unpleasant Experiences
Somewhat related to the previous point; inform patients about the possible physical and psychological sensations that may occur during and after the exercises execution. In addition, it will be very important to provide simple strategies for self-management of pain and self-dosification of exercises, so that the patient can work safely and with confidence in his or her abilities.
In addition, we ensure that if at any time you suffer a painful flare-up or worsening, you can manage your exercises and adapt your abilities.
🌏Doctors, Surgeons, Hand Therapists, Physiotherapists and Occupational Therapists around the world are already improving adherence data for their exercise programs with ReHand:
8. Integration in Daily Living
The evidence agrees that patients who achieve high levels of adherence to an exercise program are those who manage to include it in their daily life. The fact of doing it at home will be favourable, associated with the supervision of the professional.
Something as simple as adapting their exercises to everyday household activities such as brushing their teeth, preparing their meals, etc. are examples that we can use with our patients. “So that you don’t forget doing your exercises, you can include your program every day after breakfast, or before taking your dog out“.
Some barriers that may appear in center-based exercise programs like, weather conditions, lack of transport or feeling intimidation to attend a center or to be in a group. Also, home-based programs may be more engaging due to its good accessibility and relative flexibility in the timetable. As authors said:
“Only exercise programs that are in line with the preferences and characteristics of participants can become an actual habit”
9. Social Support
The integration and positive interaction with a group of patients with similar characteristics, in a positive working environment, will also help the patient to continue working in the long term. By working in a group, we will increase their confidence and reduce stress, anxiety and fear of movement.
If we are going to create groups of patients for working activeky, we should create an environment in which ALL patients feel comfortable. In this way, homogeneity in the group can achieve the positive effects of Social Support and Bonding, and therefore increase adherence.
10. Communication and Feedback
As we have already mentioned, the follow-up and constant communication with the patient is vital for them to feel confident and motivated with their therapy. Nowadays it is much easier thanks to a multitude of teleconsultation applications or apps with reminders.
Do not forget simple strategies such as phone calls or sending messages or emails. It is important that the patient feels safe and monitored if we want them to maintain the exercise programme in the long term. Recently Adam Meakins published this tweet highlighting how follow-up calls/emails are usually underrated…
It is also interesting that, after several weeks of home work, face-to-face reinforcement sessions are included to keep their motivation high and to be able to make modifications in the execution or in the programme itself.
You can read more about Telerehabilitation and the options currently available in Hand and Upper Extremity Therapy:
11. Available Progress Information and Monitoring
The graphic representation of the evolution of exercise progress, the patient’s symptoms, or the patient’s own adherence data (number of exercises performed, etc.) can mean the difference for the patient to integrate the exercises into his or her daily life.
There is a large number of studies that showed how these methods can help to objectify the patient’s evolution and encourage self-management, especially in pathologies that evolve slowly, such as osteoarthritis or chronic pain.
This idea of graphical representation to encourage self-monitoring of progress and symptoms is not new. As early as 2005, Edward Roddy et al. published some recommendations to be applied in exercise prescription. Among these points, they highlighted the use of graphic feedback for increasing maintenance. Here is an example of a ReHand Clinical Case, a DeQuervain’s Tendinopathy patient who underwent surgery, who achieved these good results in terms of adherence:
If you want to know more information about this Clinical Case, we leave you a link to the Twitter thread we made in his day explaining his situation:
12. Self-efficacy and Competence
Self-efficacy reflects the patient’s perception of the possibility of controlling his or her life and overcoming the goals ahead of him or her. In this case, with pain. Self-efficacy is the central driver of the development of human motivation, psychosocial well-being and personal achievement. (Martinez-Calderon et al. 2018)
Patient education, gradual exposure to exercise, social support from patients and professionals, etc., can change the patient’s confidence and self-esteem to improve their condition.
How can we help our patient to improve their self-efficacy skills?
An example of a study is that of V. Manning et al in 2014 in patients with rheumatoid arthritis, following the development of the EXTRA exercise programme for the upper limb, associated with education and self-management strategies. Specifically, they conducted 4 face-to-face sessions in order to facilitate behavioural changes in the patients included, following this guide:
13. Patient´s Empowerment
The pain patient must understand from the very first minute that for the therapy to be effective, active involvement on their own is necessary, and that their improvement depends mainly on them. To this end, they must integrate and learn the self-management strategies that we propose, such as exercise diaries, selection of goals, self-efficacy or self-dosification.
New technologies can help a lot in this self-management process. Specifically, the ReHand App for patients allows the inclusion of these Self-Management strategies. The exercises include a pre-exercise calibration process, which ensures that the exercise is performed safely:
14. Goal Setting
Finally, we must set realistic objectives for a period of time in agreement with the patient. They should be neither below nor above what is logically expected, so they should be well reasoned.
Objectives should be SMART: Specific, Measurable, Achievable, Realistic and Time-bound. In this way, each of these letters answers a question:
- Specific: What do I want to achieve with my patient?
- Measurable: How can I measure it?
- Achievable: Is realistic?
- Relevant: What are the benefits for the patient?
- Time Bound: When will we achieve the goal?
🥇All of these factors must be considered when prescribing any Exercise Program to our patients!🥇
Collado-Mateo D, Lavín-Pérez AM, Peñacoba C, Del Coso J, Leyton-Román M, Luque-Casado A, et al. Key factors associated with adherence to physical exercise in patients with chronic diseases and older adults: An umbrella review. Int J Environ Res Public Health. 2021;18(4):1–24.
Pablo Rodríguez Sánchez-Laulhé
Physiotherapist and Health Researcher