What have we learned about adherence to treatment?
Clearly, if we want to be successful in prescribing therapeutic exercise or telerehabilitation tools, we must be able to measure whether or not the patient carries out the prescribed treatment.
As healthcare professionals (surgeons, physiotherapists, kinesiologists, doctors or therapists) we struggle to apply different interventions to our patients: treat them, educate them, follow them, send them information… and a long etcetera that can be summed up as “giving“.
We constantly focus on what we can give to our patients and if we don’t get the expected results, our conclusion is usually:
OPTION A: What I gave my patient was not good.
OPTION B: The patient did not take/apply what I gave him/her.
In both cases, we usually discard effective treatments and we miss that the problem is that we don´t take into account other factors that may be biasing our results.
It escapes us to ask “why didn’t it work”?
Inma Villa, an excellent Spanish Physiotherapist has masterfully defined the possible causes or variables that may be responsible for this situation into an important Spanish Podcast called “FisioPodcast“, created by Rubén Hernández. You can listen to it here:
In this post, we are going to share with you our experience after 5 years of conducting clinical trials in telerehabilitation based on exercise prescription and patient monitoring in Hand-Wrist-Finger pathology.
Adherence to treatment as a determinant of successful recovery
Before focusing on what we give the patient, we should focus on how we give it. This was already said by Haynes 2002 in his systematic review published in Cochrane and WHO in 2003:
“Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”(1,2)R. Brian Haynes et al 2002
In essence, it tells us that investing in strategies to improve our patients’ adherence to treatment can have a greater impact on health than seeking to improve the prescribed treatment itself.
Here you have some important & simple Tips on how to improve adherence to exercise/rehabilitation, courtesy of Adam Meakins:
The first step in HOW we provide a specific treatment to our patient is based on communication. Therefore, we have identified three key messages that should never be missed when prescribing exercise:
1) “We are in this together”
Both of us, patient and therapist, are in this together to provide a solution to your pathology and each one of us has the capacity to act.
2) “I am going to do my part, but there is something that worries me: we have little time to work together”
We have to tell our patients that our role in this is going to be testimonial. We have just one hour out of a 24-hour day with “X” sessions in a 7-day week to be able to influence their illness.
3) “But I have good news, you have an enormous capacity to add up”
Explain to the patient his/her role, their capacity to influence in his/her illness and the opportunity that this represents. “The day has 23 more hours in which your pathology is still there and you can use this time to influence it“.
Having done this, one of the pillars of our line of research was to achieve a tool to reliably measure whether or not the patient carries out the prescribed treatment.
If we could reliably measure adherence, we could know exactly what was going on and develop possible interventions!!
Spoiler: We did it! Thanks to the ReHand monitoring system.
Now let’s get down to the really important thing: What did we observe in our clinical trials and clinical practice?
1) Adherence depends largely on us.
Those professionals who prescribed their treatment without a proper explanation to their patients, achieved adherence rates close to 0%. One example in picture below:
Patient performs some exercises on the first day and stops. Result: 1% adherence.
In contrast, those patients who received appropriate explanations about their treatment and/or did some exercises during the face-to-face session, obtained higher adherence rates. Example:
Except for the second day, the rest reached the prescribed 26 repetitions. Result: 93% adherence.
2) Patients are not liars, they have biases of their own.
When at subsequent follow-up appointments we showed patients their charts with incomplete or empty days (reflecting less than 100% compliance with treatment), most of them were surprised:
“Wow! I thought I was spending more time on my exercises!”
Most of these patients were unaware of how little they were performing their exercises, and then they got their act together and their adherence rates improved. Example:
*The arrow indicates the day we showed the patient what he/she had done so far.
3) Sometimes, unexpected events arise.
Within the ReHand monitoring system, we can send weekly validated questionnaires, so that we can compare adherence with the clinical evolution according to the questionnaires. Here is an example with QuickDASH:
One thing we have been able to observe is that patients do not evolve in a linear progression. If we look at the first score (97.73) and the last score (36.36) we can see an obvious improvement. But if we look at the intermediate scores (arrow) we can see phases where they got worse. Thanks to this system we were able to evidence this and ask our patient “what happened?”.
Most of the time, patients told us that they felt confident because of their favourable recovery and performed tasks or activities for which they were not yet prepared. Other times, there was simply an unexpected event such as a fall or a tug from the dog during the morning walk.
In the end, having this information allows us to ask him in a concrete way to be able to know these situations in his daily life, evaluate them and establish solutions such as offering the patient a progressive programme to return to certain activities or providing technical aids, protection, etc.
In our experience, we have been able to conclude that a large % of adherence rates depend on the prescriber.
We have an enormous capacity to influence this, but we often don’t ask the right questions.
As the great Inma Villa @villa_inma said:
“If we want to put the patient at the centre, the patient is the sender and we are the receiver. We have to be clear that in communication with the patient our role should be that of receiver and the patient should be the sender”.Inma Villa 2021.
Remember to check out our post about the 14 keys to promote adherence to exercise,
Haynes RB, Montague P, Oliver T, McKibbon KA, Brouwers MC, Kanani R. Interventions for helping patients to follow prescriptions for medications. Cochrane database Syst Rev. 2000 Apr 22
World Health Organization. Adherence to Long-Term Therapies: Evidence for Action. 2003.
Alejandro Suero Pineda
Physiotherapist | Hand Therapy & Surgery, eHealth and mHealth Researcher