Abstract
Prescribed home-based exercise programs have been found to be an effective non-pharmacological treatment for the management of chronic low back pain. However, such programs rely on continued patient adherence to performing the exercises. The purpose of this integrative review is to present the key factors that influence adherence to prescribed home-based exercise for individuals with chronic low back pain. Searches of AMED, SPORTDiscus, CINAHL, MEDLINE, ScienceDirect, and Cochrane Library databases were performed for the period 2015 to 2021, using the following key search terms: exercise adherence, exercise compliance, exercise therapy, home-based exercise, chronic low back pain, and enabler, barrier or factor. Eight studies met the inclusion criteria and included Qualitative, Prospective Observation, Feasibility, Case Series and Randomised Controlled Trial studies. All participants were adults ranging from 18 to 85 years old with chronic low back pain and there was an overall female representation of 53.4%. Studies were assessed for methodological quality using the Critical Appraisal Skills Programme (CASP) checklist. The findings highlighted 2 key factors influencing adherence to home-based exercise programs for individuals with chronic low back pain: (1) the need for practitioners to develop effective communication skills that focus on the individual’s needs, including personalisation of exercise programs aimed at an individual’s symptoms, lifestyle and treatment goals; and (2) follow-up feedback and support strategies via electronic (virtual) or face to face in-clinic and home visits. Adherence to home-based exercise programs requires effective practitioner communication and targeted follow-up support and feedback.
Introduction
It is estimated that 50% to 80% of adults will experience low back pain (LBP) at some stage during their lifetime. 1 An estimated 10% of LBP cases become chronic (CLBP); with pain lasting more than 3 months.2,3 Meucci et al 2 found factors that predispose low back pain sufferers to chronicity include being over 50 years old, female, smoking, having a lower economic status and lower education levels.
Chronic back pain has been consistently linked with reduced quality of life, increased psychological distress and employment restrictions. 4 Of musculoskeletal conditions, LBP is the leading cause of disability burden in all age groups. 5 Considering the significant proportion of LBP cases that develop into CLBP, this condition poses a large biopsychosocial and financial impact, with the cost of healthcare estimated to be double for those suffering from CLBP than those without. 4
Clinical practice guidelines suggest initial management of LBP should be non-pharmacological with the use the biopsychosocial framework including education, a return to normal activity and exercise. 6 Exercise is frequently prescribed to patients with CLBP by healthcare providers and numerous studies show that exercise is beneficial in reducing pain and improving function. 7 While exercise in general may improve a range of health factors prescribed home-based rehabilitation exercise programs that specifically target strength, resistance, coordination and stabilisation appear superior in the management of CLBP. 8 The effectiveness of such prescribed home-based programs is, however, reliant on patient adherence. 9
Home-based exercise refers to exercise undertaken at home or within an individual’s home environment. Such exercise programs can eliminate the barriers, such as access and cost, that are often present when exercising at public facilities including gyms, exercise studios and health clinics. Adherence, related to exercise prescription, is defined by the World Health Organisation 10 as the extent to which a patient’s behaviour aligns with the recommendations provided by a healthcare professional. Adherence in this context can be a difficult concept to measure as it is multifactorial. The various factors or variables that influence adherence to prescribed exercise fall into two broad categories: factors that enable an individual to exercise and those factors that act as a barrier.
Factors that act as barriers or enablers to adherence to a home-based exercise program can be categorised into 3 main areas: physical, socio-environmental and psychological. 11 Pain has been highlighted as a common physical barrier to exercise. A lack of motivation and perceived difficulty or ineffectiveness of exercises are reported psychosocial factors. Enabling factors include increasing motivation through goal setting, limiting the number of exercises, having social support and regular practitioner follow up that includes patient monitoring and providing feedback on exercises.12 -14 Interestingly, Noon et al 15 found that in LBP patients there is no gender difference in relation to exercise adherence.
Strategies to address exercise adherence include personalized exercise programs and improving practitioner-patient communication to increase patients’ education about their condition and the importance of exercise for recovery. It has also been suggested that patient motivation can be increased through improved communication and supervised or group activities.11,16 -18 Interestingly, research examining patient adherence to home-based exercise prescription have reported large adherence variations ranging between 35% and 72%. 19 Although similar factors affecting adherence have also been found in populations suffering from musculoskeletal conditions other than LBP, this review focuses on adherence to home-based exercise for CLBP due to the high prevalence of chronic low back pain.
Purpose
The aim of this integrated review was to identify, analyse and present the factors that affect adherence rates to prescribed home-based exercise rehabilitation programs for patients with CLBP. By understanding the factors that act as enablers and barriers to adherence amongst this population, this review offers practitioners up to date insights into the evidence of how to effectively plan and deliver home-based exercise programs for patients with CLBP.
Methods
Design
An integrated review of the literature was performed for the period 2015 to October 2021. Searching the SPORTDiscus, AMED, CINAHL, Cochrane Library, MEDLINE, and ScienceDirect databases the following keywords were used: exercise adherence, exercise compliance, exercise therapy, home-based exercise, exercise programs, chronic low back pain, lumbar pain, nonspecific low back pain and enabler, barrier, or factor. An integrated review method using a thematic analysis approach was chosen to provide a systematic method to review literature of various methodologies (experimental and non-experimental) and to comprehensively summarise and integrate the findings. 20
Search Strategy
Our initial search identified 690 journal articles, which were further defined to 25 relevant articles following review of title, abstract and duplicate removal (Figure 1). To be eligible for inclusion, articles were in English, published between 2015 and 2021, included a population suffering from CLBP, focused on prescribed home-based exercise, and factors that may influence patient adherence.
Literature Search and Selection Strategy.
Critical Appraisal Approach
To assess the methodological quality of the studies the Critical Appraisal Skills Programme (CASP) checklists were used. 21 The checklists rate research quality including the risk of bias and systematic errors, appropriate study method to answer the research question, transferability, and believable results. All authors first individually analysed the studies using the relevant CASP checklist based on the study’s methodology (one systematic review, 2 randomised control trials, 4 qualitative studies, and one case series) before group consensus was reached for all ratings. A total of 8 studies were deemed suitable with 7 studies rated to be of high quality and one study (the case series) rated as medium quality. (Table 1).
Summary of Studies Included in the Review.
Data Analysis
All 8 studies were reviewed and coded by the researchers for concepts related to home-based exercise adherence. Next, each researcher independently collated the concepts into categories of factors that increased or decreased patient adherence to exercise. To allow comparison and cross integration of the key themes and subthemes 2 researchers [GM, SM] performed further thematic analysis 22 to the adherence factors and their relationship to home-based exercise.
Results
Due to the diverse methodologies of the 8 studies, participant characteristics were broad. The pooled age range was 18 to 85 years old with a mean age greater than 38 years and an overall female representation of 53.4% (Table 1). Thematic analysis of the data identified 2 key themes and 5 subthemes related to factors that increase adherence to home-based exercise. (Figure 2). Each key theme contained several subthemes.
Factors influencing adherence to home-based exercise.
The Therapeutic Relationship Between the Patient and Practitioner
Fundamental to patient adherence is a constructive and supportive therapeutic relationship between the patient and practitioner. The influence of a positive therapeutic relationship manifests in several ways as described by the following sub-themes that emerged from the findings.
Effective practitioner-patient communication
Effective communication is an essential aspect of a therapeutic relationship. A systematic review by Barbari et al 23 found that communication and education strategies can positively affect patients with CLBP and that the addition of support-based techniques in addition to usual physiotherapy may increase exercise adherence temporarily. Although this evidence is limited, it provides insightful promise of treating CLBP in a more biopsychosocial approach.
Practitioner communication contributes to behavioural change which in turn can promote adherence to exercise. 24 In a study focussing on improving physiotherapists’ communication skills, it was found that communication based on the principles of self-determination theory provides short-term motivation for patient adherence and may provide a motivational basis for behavioural change. 25 This motivation for behavioural change may be of greater significance for long-term positive effect in CLBP patients. Lonsdale et al 25 found that empowering the patient by including them in their healthcare planning and maintaining connection via telehealth platforms had a positive impact on adherence to home-based exercise.
Patient education and exercise delivery
Another element of communication is patient education including an understanding that pain does not always equal damage. This is an important concept for patients undertaking self-directed home-based exercise programs. While some authors,26,27 suggest that reduction of symptoms, for example pain relief, is an important motivation or enabler for adherence to an exercise program, the belief that exercises are performed primarily to reduce symptoms simultaneously poses a barrier to adherence. If the exercises cause pain or have no effect on symptoms the patients are often demotivated and the exercises are abandoned.26 -28 Therefore, proper education on pain versus harm, and the purpose of individual exercises is imperative to encourage adherence. 24 This suggests practitioners should ensure patients understand that the purpose of exercise goes beyond initial symptomatic relief and that the effectiveness of exercises is not measured by their effect on symptoms in the short-term.
The role that knowledge plays in long-term exercise adherence was highlighted in the research of Saner et al 27 who found that participants with greater knowledge of the relevance of the prescribed exercises had a greater awareness of the relationship between adherence and symptomatic improvement. This study found that participant knowledge about exercises prompted the incorporation of home-based exercises into self-initiated physical activity, such as bush walking. The authors suggest that knowledge is an enabler of exercise adherence through fostering patient confidence in the effectiveness of exercise as well as promoting patient self-efficacy. This self-efficacy is especially relevant for patients with CLBP, as this condition requires continual, long-term effort for management, often without constant supervision of the health professional. Having confidence in the exercise effectiveness regardless of whether symptomatic relief is experienced in the short term relates back to the level of education delivered to patients prior to commencing a home-based exercise program.
In contrast, Nava-Bringas 26 found that participants who “dropped-out” of an exercise program had lower pain and incapacity levels at baseline, suggesting that their decision to drop out may be accounted for by their CLBP being tolerable. This suggestion could further indicate that a misunderstanding of the purpose of the exercises can pose a barrier to adherence. A participant dropping out of the study because their CLBP is tolerable is suggestive of the limiting belief that exercises are only for symptomatic relief. This is likely due to an absent or poor explanation of the purpose of the exercises. 24
Additional factors related to the importance of ensuring patients have a broad knowledge base of their condition is further evident from the research of Stilwell and Harman. 24 These authors identified fear-avoidance behaviours in patients who had an inadequate diagnostic explanation or diagnostic uncertainty of CLBP with an emphasis on pain being caused by physical structures. This suggests a need for additional training for health practitioners to improve their knowledge and communication skills regarding chronic pain including pain neuroscience education, techniques to promote psychological encouragement for example cognitive behavioural therapy and the use of graded exposure to exercise; all of which have been identified as having a potential benefit in increasing exercise adherence.
Providing patient feedback and support
Feedback and support are other important factors of the therapeutic relationship that can improve prescribed home-based exercise adherence. Feeling supported was recognised as an enabler for adherence, and includes support from the care provider as well as other CLBP patients from group sessions and social support in general.24,28 A high-quality systematic review reported that coaching-based techniques in addition to physical therapy have limited but promising evidence for positive effects on home based exercise adherence in the short term when compared to physical therapy alone. 23 This could be a result of the level of support that coaching can provide.
Feedback from care providers can be either face-to-face refresher sessions, 28 or via tele-rehabilitation technology.28,29 Easier access to care providers was another proposed enabler to adherence, such as phone calls where patients at home can have their questions answered or concerns addressed. 28 In an ethnographic study of Canadian patients with CLBP, Stilwell and Harman and Harmann 24 found that providing feedback and scheduling follow-up appointments to monitor the patient at home is imperative to patient progress.
Matheve et al 30 and Peterson 29 looked at the impact technology can have on addressing this issue. Matheve et al 30 identified that extra support is needed when managing patients with CLBP. The patients in their study felt more supported and more confident about exercise performance due to the feedback from serious games. Serious games are defined by Meijer, Graafland, Gostling, and Schijven as “interactive computer applications with specific purposes useful in the real world” 31(p1890). Although the response rate to the home exercise diaries was low and patients reported a preference for a quicker setup of the program, ultimately these patients felt motivated and satisfied throughout the whole intervention. However, this study found that no conclusions could be drawn about adherence because diary entries used to measure adherence were inconsistent throughout the study. A limited case series, with 3 CLBP patients, by Peterson 29 found that using frequent tele-rehabilitation and remote patient monitoring sessions produced positive home-based exercise adherence rates and high patient satisfaction. Interestingly, the authors suggested that these uncommonly high adherence results might be due to the participants’ high self-efficiency at baseline, a trait that has been found to be associated with higher adherence. Further research with increased participants of varying levels of self-efficacy at baseline is required to better support these findings. Although the results of this study and that of Matheve et al 30 cannot be extrapolated to the general population, they leave room for future studies to further explore the impact technology can have on home-based exercise adherence through feedback and follow up. Although new communicative technology and virtual reality advances seem attractive to some patients with CLBP it cannot replace the therapeutic relationship of face to face interactions but may be a valuable tool to overcome some isolating physical barriers experienced by patients. 28
Personalisation of exercise programs
The second main theme that positively influenced patient adherence to an exercise program was a personalised exercise program that encompassed the values of patient-centred care. The findings indicated that there were 2 primary sub-themes of the idea of a personalised exercise program: attractiveness of the exercise program and the ease with which exercise can be incorporated into daily life.
Attractiveness of the exercise program
Factors contributing to the attractiveness of exercise programs were found to be both enablers or barriers to adherence depending on the individual patient. Barriers to adherence related to the number of exercises prescribed,24,28 the complexity of exercises,24,28 exercises that were overly repetitive or boring, 28 and exercises perceived to have a low effectiveness, cause pain or have no effect on pain.26 -28 Interestingly, Palazzo 28 indicates these barriers may be related to an older demographic and patients who do not exercise frequently. On the other hand, athletes and patients who regularly exercise can have the expectation for a high number of exercises with greater variety within a challenging and progressively evolving program. 28
New technology may potentially improve the possibility of tailoring an individual’s home-based exercise program to their specific goals and likes and thus increase the attractiveness of the program. However, one major limitation of using technologies for guidance in an individual program is the at-home restriction it enforces, as this approach often requires one or multiple resources such as a computer, television, internet access or other immobile technologies. Palazzo et al 28 also found that younger patients favoured visual and dynamic technological support that provided feedback in an enjoyable and challenging environment, whereas older patients preferred being guided. Therefore, age and generational propensities may also be a determinant in whether technologies would be effective in increasing home-based exercise adherence. Although technology, such as the use of gaming, virtual interfaces 30 and tele-rehab programs 28 have been suggested as aides to encourage home-based adherence and while the use of technology appears promising, further research is required to confirm this.
Easy incorporation of exercises into daily life
A program that can allow for easy incorporation of home-based exercises into the daily life of the patient is an enabling factor for exercise adherence.27,30 Simple exercises24,27 which can be performed within daily activities can overcome the reoccurring barrier of patients “lacking time.”26 -28 Limiting the number of prescribed exercises, 24 with 4 being the maximum number, 28 also enables adherence.
Exercises that are not restricted to at-home performance or can be incorporated into other established exercise regimes can improve adherence.28,30 One study found that integration of prescribed exercises into other physical activity programs, such as group exercise sessions or other solo sessions, was a successful strategy to support adherence. 27 Focusing on the patient’s goals and having easily accessible support from the practitioner results in high satisfaction with the home-base exercise program. 29 Higher fulfilment when engaging in an exercise program appears to increase the likelihood that a patient will adapt the exercises into their life. Therefore, it is advantageous for the practitioner to appreciate the patient’s individual goals and interests to best integrate a tailored program into their lifestyle.
Discussion
Focusing on factors that improve adherence to prescribed home-based exercises in patients with CLBP theoretically should improve the health outcomes of these patients. This review found that for most patients with CLBP, key factors that improve adherence are a personalised exercise program delivered via a quality patient/practitioner relationship, appropriate patient education, providing opportunities for follow up and providing feedback either face to face or virtually using telehealth or other audio-visual aids. Recent literature discusses several means of using technology in home-based exercise prescription and patient follow-up. This updated review highlights the possibilities of technology in monitoring and improving home-based exercise adherence in patients with CLBP. There is however a need for more robust studies in this field.
While we have identified several factors that improve patient adherence to home-based exercise programs it is important to remember that few of these factors can be used in isolation. Adherence is as complex as each individual patient and will often require a multifactorial approach with effective and timely patient-practitioner communication throughout the patient’s rehabilitation journey.
Patients with CLBP who perceive that their exercise program is personalised to them are more likely to adhere to it.27,28 Personalisation in this context refers to the prescribed exercises being aimed at the patients’ specific problem, their lifestyle and socioeconomic context and the individual’s treatment goals. The perception to a patient of receiving one-on-one consults—either virtual or face to face—is critical while the exercises themselves can be generic. For individuals undertaking a home-based exercise program, practitioner connection via virtual electronic platforms or telephone can increase motivation by fostering a sense of feeling cared for and being connected to others. 25 Prescribing 4 or less simple exercises that can be easily integrated into a patient’s daily activities or existing exercise regime increases the likelihood of adherence. The type, intensity and duration of the exercises must also match the patient’s physical ability. Older patients and those with a disability often find complex exercises a deterrent to continuing a home-based exercise program. Although many patients perceive pain relief as the only goal of prescribed exercises, therapeutically there are higher goals such as increasing strength and preventing future injury. The misconception of the goal being purely to relieve pain needs to be addressed by the practitioner to increase adherence even in the face of ongoing discomfort. 26 Determining patient values in line with broader exercise goals, such as improved ability, increased strength, flexibility or relaxation can also help improve adherence. 27
A consistent finding in the literature is appropriate education of the patient. Importantly, the patient needs to understand the why and how of each prescribed exercise. Long-term adherence to exercise programs can be increased by providing sound pain education and an explanation of the purpose, prognosis and effects on pain. 27 Patient self-efficacy in the form of self-confidence has been found to be possible through careful planning of an appropriate home-based exercise regime.
Training for practitioners in pain neuroscience is important to develop the skills and knowledge needed to educate the patient about the plausible causes of pain and the effects of exercise on pain.23,25 This is especially useful to counteract patient misconceptions that a lack of immediate pain relief after exercise indicates the exercise is not working. Our findings further indicate that demonstrating the correct form of the exercise, observing the patient perform the exercise and providing feedback, although challenging in the home-care setting, is also essential for the patient to have confidence to do the exercise on their own.
Additionally, adherence increases when the patient receives at home, or in-clinic follow up at which time feedback on progress and refinement of the exercise can be demonstrated. Tele-rehabilitation technologies have been found to be a useful tool for providing such at home feedback, as they allow easier access to the practitioner.28,29 Serious games, where technology is used to provide interactive exercise activities, provides an alternative method of patient feedback and such technology has been shown to foster a sense of support and confidence within patients. 30
Limitations
There were several limitations to this study. First, our search was limited to papers available in English. Second, a broader definition of chronic low back pain could be used in the search criteria. We used longer than 3 months as our definition of chronic; however, this may have excluded potential papers. A third limiting factor of this review is the small participant numbers in most of the papers. As the papers analysed in this review did not use a standard measurement for adherence, findings from this review may not be relevant to every patient with CLBP.
Future research involving larger participant numbers should aim to determine the influence of technologies on improving adherence as well as the validity of measurement scales of adherence. Gaming technology with simulation and telehealth platforms appear to be promising areas for increasing adherence.
Conclusion
This integrative review examined the literature surrounding the barriers and enablers to prescribed home-based exercise for patients with chronic LBP. The main barriers regarding exercise adherence were related to the therapeutic relationship between the practitioner and patient, the personalisation of the exercise program to the individual patient and the difficulties of regular in-home remote monitoring and feedback. Enablers for prescribed exercise adherence include good patient-practitioner communication, patient education and careful exercise delivery ensuring appropriate patient knowledge and beliefs surrounding the purpose of exercise programs and providing feedback and support to the patient on their performance. Remote communication using Telehealth, and newer audio-visual platforms is an avenue that health practitioners can incorporated into practice to improve adherence to home-based prescribed exercise in patients with CLBP. Additionally, tailoring the exercise program to suit the individual’s lifestyle was a recurring enabler discussed throughout the literature. This includes prescribing an enjoyable exercise program with an appropriate number of exercises that are at a suitable level of complexity and can be incorporated into other physical activity and daily tasks.
Footnotes
Author’s Note
Gopi McLeod is now newly affiliated to Adjunct Visiting Fellow, School of Public Health, University of Technology Sydney, Australia.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
