Another Look at Patient Compliance

Because of its tremen-d o u s importance to what we, as health­care providers, offer the public, I want to make a few additional com­ments regarding patient compliance. Adherence to rehabili­tation programs is cru­cial to an injured patient's ability to return to activity. And, most importantly, to case reviewers, man­aged care advisors and IME doctors, hav­ing patients do these procedures them-selves-on their own time at home-is very cost-effective. The only problem is that giving patients instructions for self-care and exercises is wasteful when the patients don't comply with the instructions. Why don't they comply, and how can we get our patients to do the exercises we know they should, and, thereby, achieve more consis­tent treatment results? Compliance Research Much of the research into the likelihood of patient compliance with doctor's instructions has focused on drug regimens (which show approximately 60% non-compliance).1 Studies of exercise compli­ance have usually been involved with chronic conditions, such as diabetes, hypertension, or rheumatoid arthritis, and they have also found poor results. One recent British study of home aerobic train­ing of patients with rheumatoid arthritis concluded that "although safe, unsuper-vised home exercise programmes may benefit few patients" since the compliance levels were so low.2 Another group which studied exercise in the treatment of fibromyalgia reported that "aerobic exer­cise was the most effective treatment," but that "at follow up, there were no obvious group differences in symptom severity, which seemed to be due to a considerable compliance problem.'" Why some injured patients adhere to their rehabilitation programs and others do not was investigated in 41 college athletes (21 men and 20 women) who had sustained spoils-related injuries involving either the shoulder, the knee, or the ankle.4 Each individual had started a rehabilitation program of at least six weeks. A review of their rehabilitation records and consultation with their cli­nicians revealed that 21 of them had adhered to their programs and 20 had not. All 41 study par­ticipants completed a 40-item Rehabilitation Adherence Questionnaire that contained six scales pertaining to per­ceived exertion, pain tolerance, self-moti­vation, support from significant others, scheduling, and environmental conditions. These scales represent personal and situa-lional factors previously shown to discrim­inate adherents from non-adherents in var­ious contexts. Statistical analysis of the data showed that support from significant others con­tributed most to adherence to rehabilitation programs. Adherents perceived that they worked harder at their rehabilitation than did nonadherents, but nonadherents also rated their efforts relatively high. A deter­rent to adherence was inconvenient sched­uling. As expected, self-motivation played an important role. Also, adherents tolerat­ed the pain and discomfon of rehabilitation better than did nonadherents. Envi­ronmental conditions were the least signif­icant reasons for nonadherence. All rehab personnel should be very much aware that the injured patient who receives support from those around him, including those supervising the rehabilita­tion regime, is more likely to adhere to his/her rehabilitation program than those who receive less support. If the patient knows you care about his/her progress, he/she will be much more enthusiastic about the rehabilitation program. Oldridge5 observed that rehabilitation is influenced by a number of factors, includ­ing patient attitudes toward health and physicians, the patient's understanding of his/her illness and of the treatment pre- scribed, and his/her feelings about return­ing to past work and social situations. The patient must believe in the diagnosis and understand the concept of recurrence. Poor compliance rates are, in general, associated with medical regimens that require many restrictions or changes in personal habits, or involve multiple physicians or long intervals between referral and appoint­ment. For example, exercise rehabilitation programs for cardiac patients have relative­ly high dropout rates. A rehabilitative exer-, cise program must be perceived as having beneficial effects, and it should provide appropriate motivation, such as enjoyable exercise and. perhaps, social opportunities. Improving Compliance It may be possible to profile and, thus, identify potential rehab patient dropouts, so that appropriate entry strategies can be incorporated into exercise programs to improve compliance. Programs should contain more than an exercise prescription. Feedback on progress (or the lack of it) should be provided to the patient and spouse/parent. Other aspects that should be included in the program (where appro­priate) are relaxation techniques, proper diet, advice on sexual activity, vocational guidance and social gatherings. Improvement in functional capacity requires compliance over an extended peri­od. Group programs encourage patients to adopt and maintain therapeutic and reha­bilitative regimens by providing a health-relevant reference group of appropriate and relevant others who are in similar situa­tions. The group provides the patient with a basis for evaluating his/her progress. It's hardly surprising that a number of studies have shown supervised and/or group exercise programs to be much more effective (in terms of decreased pain, decreased disability scores, and increased fitness) than unsupervised exercising in the treatment of low back pain. The reason is ' simple: supervised patients generally com­plete more of their recommended exercise sessions than do non-supervised patients.67 But. while we know that supervision makes it more likely that patients will do their exercises, it's also obvious that super- vision of exercising is a very time-inten­sive and expensive form of treatment. In these days of cost-awareness and health price competition, we must always keep the bottom line in focus, so as not to be viewed as "expensive care". 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. Compliance with Home Programs This balance of supervision and cost-effectiveness can best be achieved by regu­lar monitoring of home exercise programs. Home exercise programs have been shown to be effective in reducing pain and in improving joint function;8 however, it is only with repeated follow-ups and some office supervision that any real compliance with home exercises can be expected. The patient must be checked on every visit to see if he/she is doing the assigned exercis­es, and doing them correctly. This gives you an opportunity to reinforce a patient's positive attitude toward home rehab, or to express disappointment with noncompli-ance. It is also a good idea to have the patient demonstrate his/her assigned exercises during an office visit. Preferably, these demonstrations should be done weekly in the early part of the treatment program. By the way, these 10-15 minute "rehab reviews" are billable services for which the doctor deserves an additional fee. One final recommendation concerning rehab: Be selective in which exercises you recommend. Keep in mind that most patients have a pretty low tolerance level and time availability for exercising. The fewer exercises you provide, the greater is the likelihood that they'll get done regular­ly. ♦ References 1. O'Brien MK, Petrie K, Raebum J. Adherence to medication regimens: updat­ing a complex medical issue. Med Care Review 1992; 12:435-454. 2. Daltroy LH et al. Effectiveness of mini­mally supervised home aerobic training in patients with systemic rheumatic disease. Br J Rheumatol 1995: 34:1064-1069. 3. Wigers SH, Stiles TC, Vogel PA. Effects of aerobic exercise vs. stress management treatment in fibromyalgia: a 4.5 year prospective study. Scand J Rheumatol 1996; 25:77-86. 4. Fisher AC, Domm MA, Wuest DA. Physician Sportmed 1988: 16:47-51. 5. Oldridge NB. Physician Sportmed 1979; 7:94-103. 6. Saal JA, Saal JS. Nonoperative treat­ment of herniated lumbar intervertebral disc with radiculopathy: an outcome study. Spine 1989; 14:431-437. 7. Reilly K, Lovejoy B, Williams R, Roth H. Differences between a supervised and independent strength and conditioning pro­gram with chronic low back syndromes. J OccMed 1989:31:547-550. 8. O'Reilly SC, Muir KR, Doherty M. Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial. Ann Rheum Dis 1999; 58(1): 15-19. About the Author Dr. Kim Christensen is Chief Operations Officer for Spine and Rehab Centers of America, a multidisciplinary public com­pany. Dr. Christensen is a popular speak­er at numerous conventions and partici­pates as a team physician and consultant to high school and university athletic pro­grams, as well as being a past chiropractic faculty member. He is currently a post­graduate faculty member of numerous chi­ropractic colleges and is the past president of the ACA Rehab Council. He has partic­ipated in college sports, and has served as a trainer, coach and team doctor. Dr. Christensen is the author of numerous pub­lications and texts encompassing muscu-loskeletal rehabilitation and nutrition. He can be reached at Chiropractic Rehabilitation Associates, 18604 NW 64th Avenue, Ridgefield, WA 98642.