Movement seems to be one of the few interventions most physiotherapists and other health care providers seems to agree that should be included in a management plan for patients with persistent pain based on evidence from systematic reviews. The last few years there have been written great articles about the potential of movement (or exercises) when treating patients with persistent pain, but how do we get people moving? I do not think I have the definite answer, but I will try to explore some of the literature regarding exercise adherence and provide a brief summary of the strategy I use when trying to get people with persistent pain moving without constant supervision.
Exercise adherence seems to be viewed by many therapists as the patients’ responsibility, but to increase exercise adherence I believe we need to take some of the responsibility and facilitate the behaviour change. I believe we need to have comprehensive knowledge about the barriers and facilitators, and learn to incorporate strategies that have the potential of facilitating people with persistent pain to adhere to exercise/movement/physical activity in the long-term.
A recent clinical update from Booth et al., (1) wrote “A better understanding of strategies to improve treatment adherence such as goal setting, self‐monitoring and professional feedback is required.” A Cochrane review concluded that there was moderate evidence to suggest that self-management programs and the inclusion of interventions based on cognitive and/or behavioural principles could help some groups of people with persistent musculoskeletal pain improve exercise adherence (2). However, only 18 of the 42 RCTs showed that their interventions successfully enhanced adherence to exercise or physical activity in people with persistent musculoskeletal pain (2). Incorporating specific adherence enhancing strategies within an exercise program, including behaviour change techniques such as social support, goal setting, demonstration of behaviour, graded tasks and self-monitoring of behaviour have been shown to increase exercise adherence among people with persistent pain (3, 4).
"Everybody knows we should prescribe exercises, but should we start talking more about strategies to increase adherence? Everybody knows that movement is good, but how do we get people with persistent pain moving?"
Barriers to exercise adherence and possible strategies to overcome these
We have all heard why people do not exercise and we have all probably experienced many of the same barriers. Lack of time, lack of motivation, lack of energy, and that exercise increase pain are some of the most common (5, 6). We need to find strategies that can be used to challenge and change these barriers to exercise adherence . We need to define barriers for long-term adherence to exercises (problem definition), suggest solutions to overcome these barriers (generation of possible solutions) and based on shared decision-making we should make action plans that the person in front of you feels confident they will be able to do (solution implementation) (5). Some examples: If a person says, he/her does not have the time to exercise, we should consider identifying available time slots in their weekly routine. We could also consider incorporating exercise into daily routines. We could recommend walking/bicycling instead of driving to work. If lack of motivation is a barrier, we could discuss the benefits of exercise, and set short- and long-term goals that are tailored to the patient to hopefully increase motivation. To make the exercise program less boring, we could tailor the exercise program to the patient’s personal preferences. If lack of energy to exercise is a barrier, we could discuss that regular exercise will increase energy over the longer term and can improve sleep quality. If pain is a barrier, we could reassure by saying that pain is often felt when people with persistent pain exercise and that this is normal and safe, and that this does not mean that exercise is harmful, as long as it is acceptable to the patient.
A strategy to increase adherence to exercise/physical activity
Lorig & Holman have provided five core self-management skills which I find very helpful when trying to get people moving without constant supervision: Problem solving, decision making, resource utilization, forming of a patient/health care provider partnership, and taking action (7). I will try to operationalize I work with these skills when trying to increase adherence to self-managed exercises among patients with persistent pain.
1. Problem solving
During the first session the focus will be on actively involving the patient in how to keep a good performance level of exercises or how to improve their ability to exercise. The barriers for long-term adherence to exercises will be defined (problem definition), concrete solutions to overcome these barriers will be suggested based on shared decision-making (generation of possible solutions), and a brief set of 1-3 exercises (because of higher odds of adherence (8)) for the coming week will be agreed upon (solution implementation).
2. Decision making
During the second session the decision-making process will be the main focus. The experiences from the first week(s) will be used to go into a more thorough discussion around how to implement a behaviour in line with adherence to exercises and how to become more confident in managing their shoulder pain by themselves. For example, the physiotherapist might consider that the participant needs more knowledge in order to meet the goal of long-term adherence to shoulder exercises. This can be related to topics such as how to deal with pain during or after the exercises, what is the optimal dosage of exercises/physical activity, and/or how to deal with fears and worries related to exercises and physical activities. The topic can also be how to organize the daily life in order to prioritize the shoulder exercises.
If pain is experienced whilst exercising the participant will be told that as a rule of thumb it should be acceptable upon cessation or return to an acceptable pain level within 24 hours. The participant will be encouraged to judge what is acceptable. If the participant experiences unacceptable pain during or after the exercise sessions, they will be advised to cut back on the exercise dosage and try to find a comfortable exercise level, stick to this for 1 or 2 weeks, and add to it by 10 to 20% every 7 to 14 days. We will also explore the patients’ perception about exercising discussing aspects such as; “What do you think will happen when you perform this exercise? Do you think this exercise is dangerous for you?” (9).
This part also ensures that the intervention will be personalised. Based on the assessment and the comprehensive baseline questionnaire the management will emphasise key issues, such as graded exposure to feared movements for patients with kinesiophobia and/or low pain self-efficacy, discussing the importance of physical activity for patients not meeting current physical activity recommendations (<150 minutes moderate activity per week), managing poor sleep, dealing with depression, anxiety and low mood and how to manage pain “flare-ups”. Management by a multidisciplinary team including health care practitioners with psychological expertise should also be considered.
3. Resource utilization
This skill is related to teaching the participants in how to use available resources that might help them stay adhered to exercises and to reconceptualise unhelpful thoughts, pain beliefs and behaviours. I will encourage the patient to identify beneficial resources in their local environment, such as a local gym where they can exercise. I will also encourage the patient to do web lessons to learn more about the biopsychosocial nature of pain at retrainpain.org. The resources will be utilized after the first session and the patients’ interpretation of these resources will be the basis of the conversation in the following session. Remember to let the patient get time to talk during this session. They will usually pick up the topics that they find most interesting and that is always a good start for a meaningful conversation.
4. Forming of a patient/health care provider partnership
The forming of a therapeutic alliance will include goal setting based on patients’ personal preferences by using the Patient Specific Function Scale. The patient will also be able to contact me when they are uncertain about how to manage their shoulder pain by themselves. To strengthen the therapeutic alliance we will also allow patients to tell their story, provide emotional support, chat with the patient in a friendly manner and to motivate and show encouragement (10-13).
5. Taking action
Taking action reflects skills that are involved in learning how to change a behaviour. I will usially make an action plan for the next 1-3 weeks, together with the person at the first consultation. The action plan will contain information about the time points for exercises and/or other physical activities, the amount (number and length of sessions) and modifications of the exercises based on individual pain acceptability. In relation to self-management theory, the action plan needs to reflect something that the person is fairly confident to accomplish. Level of confidence will be measured by asking the person how confident they are that they will do what is described in the action plan. The person will score their level of confidence on a numerical rating scale from 0 (totally unconfident) to 10 (totally confident). If the answer is 7 or higher, based on self-efficacy theory, there is a good chance that the action plan will be accomplished. If the answer is less than 7, I will encourage further problem solving in order to make the plan more realistic and to avoid failure. This usually involved decreasing the number of exercises due to time constrains.
During the last individual sessions, a long-term action plan will be developed together with the patient. In this plan, physical activities that may replace or supplement the exercise program is discussed. This plan will be strongly tailored to the individual and contain valued activities. The person will be strongly encouraged to continue an active-lifestyle in relation to physical activity.
Joyful activities (in my opinion). Photos: Daniel H. Major and Yngve Røe
Hope you will give this strategy a go! It has made me more confident and strategic when trying to get people with persistent pain moving on their own and we have seen good results in our feasbility study among patients with persistent subacromial pain (14).
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