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Why is patient compliance in physical therapy important?
65 - 75% of physical therapy patients end up not completing their treatment plan [1]. Patients do not return to scheduled visits, and/or they do not do their exercise homework at home. This ends up costing physical therapy clinics $100’000s per year in missed revenue.
From a health outcome perspective, Rutten finds that adherence to rehabilitation plan results in superior functional capacity, and fewer treatment sessions [2]. Deyle finds that a combination of physical therapy and exercise results in superior functional outcomes, and delays or precludes the need of surgery in knee osteoarthritis patients [3].
Now that we have a sampling of the health and business benefits of physical therapy compliance, let’s examine what patient compliance is, why it is a challenge, and how can a clinic improve compliance.
These questions are not straightforward and we are not aware of a golden solution. We love learning, so please get in touch if you have information to share!
Patient compliance physical therapy and medical definition
We will take a step in the direction of resolving these questions by investigating the literature, and thinking through it. While not all of the literature review is specific to physical therapy, it is medical literature that does not preclude the applicability to physical therapy.
First things first: what is the definition of patient compliance? Is patient compliance the correct term to describe the challenges at hand?
According to Merriam-Webster, compliance is the
“the act or process of complying to a desire, demand, proposal, or regimen or to coercion”.
Yikes!
A couple of the implications here are outright negative - demand & coercion [4]. We can see that by default, there may already be an uphill battle in securing patient compliance.
How about patient adherence? The term carries a similar, perhaps slightly less demanding connotation of “sticking” to a plan, yet still implies a paternalistic model of medicine.
Next let’s look at the definition of the term patient. The first definition in Merriam-Webster is “a person who is under medical care or treatment”. An archaic definition of the term refers to ‘sufferer’ or ‘victim’. Is this the same medical treatment plan that ‘compliance’ is associated with?
Through this brief exercise in semantics, we can start to see a potential issue at hand: the traditional medical model of patient compliance may have the best intentions in mind, yet may be working against clinicians from the outset.
Patient compliance parallels with the service industry
So how can we look at the same problem through a different perspective? Let’s take a look at solutions elsewhere - the service industry. Restaurants, hotels and other service industry establishments succeed or fail, as measured by the customer perceived success in serving their customers.
Some physical therapy clinics may have lucrative contracts with local and/or in-network hospitals, to where patient satisfaction is not of great importance.
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However, the service industry lives and thrives or perishes by the satisfaction of their customers. We believe that cash-based physical therapy clinics and service industry businesses are somewhat similar. In the long-run, we believe a greater part of the physical therapy industry will resemble cash-based physical therapy practices, and thrive by their successful service of customers.
At a service business, the customer is placed at the forefront of business decisions made. Success or failure depends largely on the level of customer service received.
Similarly in physical therapy, the customer can choose to hire or fire the clinic at any given instant. Customers have choices, and can select to not pursue physical therapy, to seek alternative providers, or worse - resort to higher risk treatments in opioids or surgery. The latter is undesirable in scenarios where health outcomes from PT are superior or comparable.
So how can we think about the patient as our customer? How can a clinic better serve its’ customers? Let’s dive in!
Patient compliance literature review in context of physical therapy
Recognizing that each customer is unique, has a different background, expectations, and beliefs is an important starting point to improving the level of service, and ultimately improving compliance.
In one of the earliest comprehensive studies on patient adherence to physical therapy, Slujis identified that 35% of patients fully complied, while 76% partly, not wholly, complied with their treatment plan [1]. Slujis identified three main barriers to non-compliance:
(1) the barriers patients perceive and encounter,
(2) the lack of positive feedback, and
(3) the degree of helplessness.
On barriers patients perceive, modifying the treatment plan to account for the patient’s lifestyle can be approached from the outset. This approach ties into shared-decision making, on which we will discuss below.
On feedback, Slujis found a correlation between positive feedback and increased compliance, noting that it causality between the two is unknown. The way a patient feels (e.g. pain or no pain), and how a clinician evaluates and communicates to their patient are two traditional ways of progress tracking.
Finding an evidence-based, and neutral third party to help track, visualize movement and demonstrate progress could help patients. Wand et. al. found that in low back pain patients who moved with visual feedback both post movement pain intensity, as well as time to ease were both less than in LBP patients who moved without visual feedback [22].
Finally, Slujis mentions that the ability to perform exercises, and the patient’s understanding of exercise can affect adherence. Understanding these concerns and tailoring the treatment plan accordingly from the beginning could help with adherence.
McKelvie shows that physical therapy and physical therapists make a difference in the lives of their patients, as evidenced by greater adherence in-person than at-home PT program [5]. It can be hypothesized that the PT does a better job of 1) educating, 2) motivating their patient and/or 3) personalizing the rehabilitation program, than the patient by themselves.
Schneiders finds that there is a significant improvement in home exercise compliance when there is a multimodal patient education strategy when comparing a group who received verbal only instructions, as compared to a group receiving text and visual instructions (in form of a leaflet) [6]. More recent studies agree with the multimodal approach, showing that healthcare IT solutions used to enable patient-centered care can have a positive effect on health outcomes [16].
In the context of medication, complexity and inconvenience are suggested to impact adherence. In tracking multiples-times per day medication intake, Eisen found 84% compliance for one-a-day medicine intake, vs. 59% for three-a-day [7].
Atreja et al. [8] suggest a SIMPLE framework consisting of Simplifying “regimen”, Imparting knowledge (education), Modifying patient beliefs, improving Patient communication, Leaving bias, and Evaluating adherence. While the SIMPLE framework was constructed with medication adherence in mind, we can extract a few insights from the recommendation.
First, the author acknowledges implicitly that patients have beliefs, and that they must be considered. Simplifying treatment plans and improving communication are recommendations easily transposed to physical therapy. While physical therapy exercises can be more complex and difficult than taking and adhering to medications, Atreja points to methodologies on making education simpler and more accessible.
Atreja then examines the clinician’s understanding of patient beliefs and their potential effect on adherence: vulnerability, condition severity, perceived benefits, barriers affecting treatment (e.g. fear), and self-confidence in carrying out the treatment program.
Next, communication is cited as a common barrier. Asking your patient questions on how they are feeling, where they are coming from, learning about their beliefs, and what concerns or preconceptions they hold in their treatment plan is a good start to building a rapport.
On bias, there is weak correlation between perceived patterns of previous patients exhibiting non-adherence. A way to overcome unconscious biases is to approach each new patient with open ended customer discovery questions designed to understand their beliefs and concerns - e.g. “Tell me about your (expectations/beliefs…).... What are your concerns?; What are your objectives? What barriers do you foresee in working towards your objectives?; How can we work to overcome these barriers together?
Finally, Atreja comments that without measurement, it is difficult to detect non-compliance.
Specifically, for patient compliance in physical therapy, it is important to consider a numeric or even multiple measures of compliance. Is our metric of compliance measuring performing homework or at home corrective exercises? Are we measuring premature departure from the treatment plan? Or do we count the percentage of missed visits? How is the patient progressing as by measured during repeat visits?
At EuMotus, we have developed a clinical motion analysis product that evaluates rehabilitation progress longitudinally, and serves as a communication aide for use by the clinician with their patient. Feedback from our clients indicates that patients are more engaged, even excited, and are eager to prove to themselves and their clinician that they are getting better. EuMotus client feedback indicates a 20% increase in patient retention, by way if integrating EuMotus BodyWatch motion analysis into the clinical process. Get in touch to speak with a team member about improving patient retention by writing us at hello@eumotus.com.
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But why does patient engagement matter? In the context of chronic disease (not necessarily physical therapy), studies have shown that patients who are more engaged - as defined by wanting to know, and own more of their recovery process - are likely to achieve greater ownership of their own health and recovery process, and accordingly achieve superior health outcomes [17-21].
Relating treatment plan tasks and objectives to patient personal beliefs
Lequerica et. al. [9] found that explicitly tying back treatment plan objectives and tasks back to personal goals and beliefs was a common best practice for increasing patient engagement. The author sampled hundreds of USA based physical therapists and occupational therapists on how they improve patient engagement.
Approaching patient engagement through shared decision making
In the early 2000s Vermeire et. al. conducted a comprehensive review on the topic of patient adherence (centered on medication use) [10]. The authors found that the role or importance of the patient was largely absent in discussions on adherence, reflective of a paternalistic medical attitude. Vermeire advocated to shift away from a paternalistic doctor-patient model to one of a partner/trust and shared-decision making model and to bring the patient to the center of discussion on adherence and effective treatment strategies. The author also found that definition of compliance was absent from multiple studies and inconsistent amongst others. Vermiere presented a case of preference for the less harsh sounding adherence, in lieu of compliance.
No strong correlation was found between a single variable and patient compliance.
However, the authors did mention that “constraints of everyday life” (i.e. behavior change) and the patient’s beliefs were instrumental factors of patient compliance.
Improved education and behavioral strategies through multimodal means of communication (written, verbal etc.) has shown to demonstrate a positive effect on patient adherence [11][12].
EuMotus clients use a combination of video playback, and concise patient avatar visual analytics to convey movement health, as a complement to clinician instruction. Patients love seeing themselves on video. Clinicians use the moment of patient engagement as an opportunity to further gain patient buy-in. Some clinicians challenge their patient by setting goals, getting measured using the clinical motion analysis product, and therefore making and marking progress through the rehabilitation process.
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Vermiere makes a strong case for viewing patient adherence as the domain of the patient, as the ultimate party responsible for treatment success and the party that will live with the results (or lack thereof) of any particular treatment plan. It is the responsibility of the medical provider to ensure that the treatment plan, education and communication with the patient is designed to capture patient engagement.
Shared Decision Making in context of physical therapy
Devisch et. al. [13] take the share decision making framework and theory and apply it specifically in the context of physical therapy. Devisch finds a correlation between share decision making and autonomy in physical therapy. While causality is not clear, and a small sample size of physical therapists in a specific geography, the author makes the recommendation for PTs to ask questions, involve the patient, provide information, and avoid the traditional paternalistic method, as the patient is the ultimate expert on their capabilities, lifestyle, and therefore ability and motivation to adhere to a treatment plan.
Strategies to improve patient adherence
Jack [14] resumes Vermeire’s comprehensive patient adherence and focus the question on physiotherapy or physical therapy. Among a variety of study subjects, several variables strongly correlated with adherence were barriers to exercise, patient foreseen difficulties in execution of exercise homework, difficulty and worsening of pain during exercise, initial ramp up and adherence to exercise in first four weeks.
On self-efficacy, Kirsten found in the review of studies that treatment plans should be tailored to individuals (this involves an honest relationship and ongoing dialogue with the patient). The treatment plan should have objectives set. Accordingly, realistic expectations should be set (again, this is centered on capabilities and motivations of the patient). Patients are humans and humans are social. An element of support is required and could take the form of coping planning and positive reinforcement
Barriers to exercise revolve around behavior change. Work and personal schedule and needs may dictate availability. This can be mitigated by setting up a treatment plan ahead of time. On convenience and forgetting, the clinician is best suited to employ technology in reminders, constant communication and homework tools.
Kirsten refers to strong correlation on adherence by way of Schoo’s work where subjects with osteoarthritis who were adherent in the first four weeks, were twenty times more likely to be adherent in the final four weeks [15].
Finally, Kirsten mentions that despite the extensive literature on adherence from the past several decades, gaps remain, such as the “lack of research investigating barriers introduced by health professionals and health organizations”.
Applying Shared Decision Making in the context of physical therapy
While the importance of physical health and movement is the physical therapist’s education and professional focus, a lack of a similar background in patient can lead to a lack of adherence.
Based on the principle of shared decision making,
The clinician should strive to understand the patient’s attitudes and motivation, and their beliefs and education.
The clinician should aim to communicate in a (or perhaps multiple) clear way(s), using all tools available to obtain the patient’s engagement and buy-in.
Finally, the clinician should probe the patient to understand and identify any barriers, which may affect adherence to the treatment plan.
So what patient engagement strategies have worked at your clinic? We’d love to hear from you at hello@eumotus.com!
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References
[1] Sluijs EM(1), Kok GJ, van der Zee J., Correlates of exercise compliance in physical therapy. 1993 Phys Ther. 1993 Nov;73(11):771-82; discussion 783-6.
[2] Rutten GM1, Degen S, Hendriks EJ, Braspenning JC, Harting J, Oostendorp RA. Adherence to clinical practice guidelines for low back pain in physical therapy: do patients benefit? Phys Ther. 2010 Aug;90(8):1111-22. doi: 10.2522/ptj.20090173. Epub 2010 May 20.
[3] Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC. Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee: A Randomized, Controlled Trial. Ann Intern Med. ;132:173–181. doi: 10.7326/0003-4819-132-3-200002010-00002
[4] Merriam-Webster. https://www.merriam-webster.com. Accessed Sep 2018.
[5] McKelvie, R. S., Teo, K. K., Roberts, R., McCartney, N., Humen, D., Montague, T., ... & Yusuf, S. (2002). Effects of exercise training in patients with heart failure: the Exercise Rehabilitation Trial (EXERT). American heart journal, 144(1), 23-30.
[6] Schneiders, A. G., Zusman, M., & Singer, K. P. (1998). Exercise therapy compliance in acute low back pain patients. Manual Therapy, 3(3), 147-152.
[7] Eisen SA, Miller DK, Woodward RS, Spitznagel E, Przybeck TR. The effect of prescribed daily dose frequency on patient medication compliance. Arch Intern Med. 1990 Sep;150(9):1881-4.
[8] Atreja A, Bellam N, Levy SR. Strategies to Enhance Patient Adherence: Making it Simple. Medscape General Medicine. 2005;7(1):4.
[9] Lequerica AH, Donnell CS, Tate DG. Patient engagement in rehabilitation therapy: physical and occupational therapist impressions. Disabil Rehabil. 2009;31(9):753-60. doi: 10.1080/09638280802309095.
[10] Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther. 2001 Oct;26(5):331-42. Review.
[11] Haynes RB, McDonald H, Garg AX, Montague P. Interventions for helping patients to follow prescriptions for medications. Cochrane Database Syst Rev. 2002;(2):CD000011. Review. Update in: Cochrane Database Syst Rev. 2005;(4):CD000011. PubMed PMID: 12076376.
[12] Morris LS, Schulz RM. Patient compliance--an overview. J Clin Pharm Ther. 1992 Oct;17(5):283-95. Review. PubMed PMID: 1464632.
[13] Ignaas Devisch, Katreine Dierckx, Dominique Vandevelde, Patricia De Vriendt, Myriam Deveugele (2015) Patient’s Perception of Autonomy Support and Shared Decision Making in Physical Therapy. Open Journal of Preventive Medicine,05,387-399.
[14] Jack, Kirsten et al. “Barriers to Treatment Adherence in Physiotherapy Outpatient Clinics: A Systematic Review.” Manual Therapy 15.3-2 (2010): 220–228. PMC. Web. 17 Sept. 2018.
[15] Schoo, A. M. M., Morris, M. E., & Bui, Q. M. (2005). The effects of mode of exercise instruction on compliance with a home exercise program in older adults with osteoarthritis. Physiotherapy, 91(2), 79-86.
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[17]A National Action Plan To Support Consumer Engagement Via E-Health
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[21] mohamed_hassan via https://pixabay.com/en/feedback-satisfaction-employee-3240007/ . Accessed September 2018.
[22] Wand BM, Tulloch VM, George P, Smith AJ, Goucke R, O’Connell NE, Moseley, GL. Seeing It Helps: Movement-related Back Pain Is Reduced by Visualization of the Back During Movement. The Clinical Journal of Pain. September 2012. Vol. 28. Iss. 7. 602–608.
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