Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review

Hull & East Yorkshire Hospital, Anlaby Road, Hull HU3 2JZ, United Kingdom.
Manual therapy (Impact Factor: 1.71). 02/2010; 15(3):220-8. DOI: 10.1016/j.math.2009.12.004
Source: PubMed


Poor adherence to treatment can have negative effects on outcomes and healthcare cost. However, little is known about the barriers to treatment adherence within physiotherapy. The aim of this systematic review was to identify barriers to treatment adherence in patients typically managed in musculoskeletal physiotherapy outpatient settings and suggest strategies for reducing their impact. The review included twenty high quality studies investigating barriers to treatment adherence in musculoskeletal populations. There was strong evidence that poor treatment adherence was associated with low levels of physical activity at baseline or in previous weeks, low in-treatment adherence with exercise, low self-efficacy, depression, anxiety, helplessness, poor social support/activity, greater perceived number of barriers to exercise and increased pain levels during exercise. Strategies to overcome these barriers and improve adherence are considered. We found limited evidence for many factors and further high quality research is required to investigate the predictive validity of these potential barriers. Much of the available research has focussed on patient factors and additional research is required to investigate the barriers introduced by health professionals or health organisations, since these factors are also likely to influence patient adherence with treatment.

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    • "The cognitive illness representations we asked about in this interview are composed of five interrelated components: identity (the symptoms and the 'diagnostic label' associated with the illness), causal beliefs, timeline beliefs, beliefs about control/cure and consequences.[36] To measure perceived barriers that may hinder behavioural performance, we used a barrier list containing barriers described in recent adherence research and corresponding with the setting of this study.[14,15,19] Appendix 1 shows how the barrier list is adjusted. "
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    ABSTRACT: The aim of this cross-sectional observational study was to investigate adherence rate and factors influencing the adherence in following home-based activity advice, in patients referred to a physiotherapy clinic for non-specific low back pain. Research suggests that inadequate adherence to home-based activity advice during an intervention period may diminish treatment outcomes. Factors negatively influencing adherence appeared to be related to a person's beliefs and perceptions. Perceived barriers, low self-efficacy and unbeneficial illness beliefs have been consistent predictors for non-adherence across studies. 51 patients who reported non-specific low back pain were advised to walk daily. Physical activity was measured with a validated triaxial seismic accelerometer. The effect of multiple patient-related determinants on the rate of adherence was studied. Only four out of 51 patients (8%) fully adhered to the walking advice. In this study, there were no significant effects of patient-related determinants on the rate of adherence. Factors negatively influencing adherence behaviour were lack of time, weather conditions and increasing low back pain. In conclusion, patient adherence in following home-based activity advice for non-specific low back pain outside the clinical setting is poor.
    Full-text · Article · Jan 2016
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    • "In clinical practice it would be unusual to do a diagnostic procedure before considering a therapeutic intra-articular facet joint injection; the diagnosis of probable facet joint pain is usually made on clinical grounds alone. Continuing pain, or increasing pain during physiotherapy or other exercise, is cited as a barrier to engagement with physiotherapy interventions[8]. Even short-term pain relief following facet joint injections might facilitate rehabilitation and improve patient outcomes. "
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    ABSTRACT: Background: The role of injections of therapeutic substances into the back as treatment for low back pain is unclear. Facet joint injections are widely used despite the absence of evidence of sustained benefit. We hypothesise that facet joint injections might facilitate engagement with physiotherapist-led, best usual care (a combined physical and psychological programme) and is a clinically and cost-effective treatment for people with suspected low back pain of facet joint origin. Methods/Design: We present here the protocol for a randomised controlled feasibility trial for a main trial to test the above hypotheses. Patients referred to secondary care with persistent non-specific low back pain will be screened and invited to take part in the study. Those who meet the eligibility criteria will be invited for a physiotherapy assessment to confirm trial eligibility and for baseline data collection. All participants (n = 150) will be offered the best usual care package with physical and psychological components. Those randomised into the intervention arm (n = 75) will, in addition, receive intra-articular facet joint injections with local anaesthetic and steroids. Primary outcome data will be collected using daily and then weekly text messaging service for a pain score on a 0-10 scale. Questionnaire follow-up will be at 3, 6, and 12 months. Evaluation of trial processes and health economic analyses, including a value of information analysis, will be undertaken. The process evaluation will be mixed methods and will include the views of all stakeholders. Discussion: Whilst this trial is a feasibility study it is currently one of the largest trials in this area. The outcomes will provide some evidence on the use of facet joint injections for patients with clinically diagnosed facet joint pain.
    Full-text · Article · Dec 2015 · Trials
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    • "A recent systematic review reported 61 measures of patient adherence to home based exercise programmes with almost all lacking psychometric validation[38]. This review also did not address the barriers to adherence and why some patients are more likely to adhere than others although this has been reported elsewhere[14]. It should be argued that just because one component of study design (such as blinding of subjects and/or therapists) cannot be successfully applied in many physiotherapy intervention studies, it does not mean that physiotherapy research is inferior[32,33]. "
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    ABSTRACT: Background: Physiotherapist prescribed self-management strategies are an important adjunct to 'hands on' treatment. However, treatment outcomes are likely to be related to whether patients adhere to the prescribed strategy. Therefore, physiotherapists should be aware of adherence aiding interventions designed to maximise patient outcomes underpinned by quality research studies. Objective: To conduct a systematic review of the interventions used to aid patient adherence to all physiotherapist prescribed self-management strategies. Data sources: The search included the databases CINAHL, EMBASE, MEDLINE, PUBMED, PSYCINFO, SPORTSDiscus, the Cochrane Central Register of Controlled Trials, PEDro and Mednar for randomised controlled trials (RCTs) published in a peer reviewed journal from inception to November 2014. Data extraction and synthesis: Data were extracted using a standardised form from twelve included RCTs for patient adherence rates to self-management strategies for interventions used to aid patient adherence and usual care. Two independent reviewers conducted methodological quality assessment. Results: Twelve different interventions to aid patient adherence to exercise were recorded from twelve fair to high quality RCTs. Potential adherence aiding interventions include an activity monitor and feedback system, written exercise instructions, behavioural exercise programme with booster sessions and goal setting. Conclusion and implications of key findings: Despite a number of studies demonstrating interventions to positively influence patient adherence to exercise, there is insufficient data to endorse their use in clinical practice. No RCTs examining adherence aiding interventions to self-management strategies other than exercise were identified, indicating a significant gap in the literature.
    Full-text · Article · Oct 2015 · Physiotherapy
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