Poor rehabilitation adherence may lead to sub-optimal treatment outcomes, reduced clinic efficiency and increased cost of care. But despite this knowledge, research indicates that attendance at physiotherapy departments is within 54%-94%and can be as low as 40%. Several studies confirm that adherence to a clinic-based exercise protocol is often around the 50% markand may be particularly poor for unsupervised home exercise programs.
In order to develop an indepth understanding of the factors influencing attendance (AA), in-clinic adherence (ICA) and home exercise adherence (HEA), my PhD research involved a multi-phase mixed methods study which included an initial systematic review and meta-ethnography, followed by a prospective cohort study and qualitative exploration of emerging factors through interviews with patients and reception staff and focus groups with physiotherapists and clinical managers. Finally a triangulation protocol was used to integrate and conceptualise the findings from all these stages. While a wide variety of themes were identified from over 136 different factors which were analysed, a positive therapeutic relationship emerged as the sole factor which influenced all three aspects of rehabilitation adherence (AA, ICA, HEA).
The concept of therapeutic relationship was first highlighted by Freud (1913) within the domain of mental health. He suggested that “The first aim of the treatment consists in attaching [the patient] to the treatment and the person of the physician”. Since then, therapeutic relationship and its impact on patient adherence and satisfaction have been well documented across medical literature.
In the context of my findings, therapeutic relationship doesn’t just denote the collaborative bond or transference relationship between a patient and the therapist, but also represents the essential integrative variable denoting the relationship between the patient, their physiotherapist and rehabilitation adherence. Physiotherapists and policy makers frequently lay the blame for non-attendance and non-adherence on the patient. This is reflected in the CSP’s definition of DNA’s which underlines the patient as the cause of DNA without taking into account the complexity and the numerous interactions which influence attendance and subsequently ICA and HEA –
“A DNA is a wasted appointment slot, caused by a patient who does not attend an appointment (whether they cancel or do not turn up on the day)” (CSP 2011)
This stance by the CSP also resonates in the attendance policies of most physiotherapy departments. If a patient does not attend an appointment, cancels with less than 24 hours’ notice or cancels their appointment twice, they can be discharged from their treatment.
Patient therapist communication
A clear channel of communication where a patient feels able to vocalise their concerns was considered to be the bedrock of a therapeutic relationship. The key aspects to facilitate adherence was the need for physiotherapists to listen, understand and empathise with the patients. It was deemed important that a physiotherapist is able to understand the concerns of the patient and respond to their needs. Failure to adopt a clear channel of communication where a patient feels that their concerns have not been addressed, the treatment aims and goals have not been discussed and clarified leads to loss of trust and rapport with the patients. In such a situation, patients may lose confidence in them and decide to move to a different physiotherapist.
A key aspect of initial patient-therapist communication is the provision of information about what physiotherapy would entail to ensure that patient understands the physiotherapeutic process as well as the aims of treatment. Provision of written appointment times by the reception team was also seen as a way of reminding the patients to attend their follow up appointments.
Provision of written exercises along with detailed explanation and demonstration of the exercise program were the key elements of patient therapist communication. All participants discussed the importance of written exercises as a reminder to adhere to exercise program. Patients also considered that it acted as an ‘aid memoir’ and thus ensured that they did their exercises regularly. It was also discussed that written exercises and the demonstration in-clinic gave the patients confidence that they are doing it correctly.
Patient-therapist communication was also discussed in relation to the in-clinic rapport between them and subsequent trust that a patient is willing to place in the advice of the physiotherapist. If a patient trusted the physiotherapist and the rationale provided for continuing the exercises, they may overlook pain aggravation as a temporary barrier and work through the pain to continue their exercises.
Effectiveness of physiotherapy treatment
Participants felt that if physiotherapy was effective in managing the symptoms and achieving desired goals for the patients, then it led to continued attendance. However, continued lack of effectiveness and non-impact on their presenting problems was seen as a barrier to attendance. In contrast, if the exercise program led to adverse events such as increased pain levels, fatigue or exacerbation of other symptoms, it may lead to anxiety in the patients and they may make a decision to drop out of the program altogether.
Continuity of treatment
Being seen by the same physiotherapist over the course of their treatment was considered to be an important factor in continued attendance. Managers reported that sudden sickness absence of the treating physiotherapist may force the appointments to be cancelled and rescheduled. Patients’ may perceive lack of any benefit from physiotherapy due to long gaps in treatment due to multiple rescheduling or cancellation of appointments. This may impact on future attendance.
Continuity of care was also affected by patient’s preferences for specific appointment times. Patients have preferences for specific appointment times considering their individual and family circumstances. It was considered that generally elderly patients and young students did not want early morning appointments. The elderly get free bus travel in the late mornings while the youngsters prefer a lie in. Patients who have children may prefer appointments which are during school times, so that they do not need to worry about childcare. These preferences reduce the availability of appointments for the patients.
Adaptation of exercise program to patient’s specific needs
Patients may have varying preferences for the type of exercises and nature of supervision by a physiotherapist. While some may prefer individual exercises with close supervision, others may like to be in a group session or exercise class with minimal input from the physiotherapist. Similarly, patients may have specific preferences for appointment times and activity patterns. Ensuring that the exercise program is relevant to the patient’s needs and goals was seen to be an important factor in facilitating attendance by all groups of participants. Participants felt that unless the exercise program is oriented to meet the goals of the patient and not just the outcomes which physiotherapist is able to measure, it may lead to participants dropping out of treatment.
Implications for policy and practice
Therapeutic relationship is a two way interaction with the patient but due to the patient’s dependence on the service provided by the physiotherapist, there may be an imbalance of power in this relationship. Therefore physiotherapists need to examine their own important role in contributing to non- adherence and appreciate what they themselves might be able to do to facilitate rehabilitation adherence.
Physiotherapist should endeavour to see the problem from the patient’s perspective and worldview, understand their feelings, expectations and fears. This involves discussion and agreement on the nature of problem being experienced by the patient. It also includes provision of information and meaningful rationale for the treatment approach being provided to promote patient choice and to enable the patient to make informed decisions. These can be achieved through an empathetic approach and active listening where the patient is given time to explain their problem and ask questions from the physiotherapist. Positive communication between a patient and physiotherapist also includes provision of clear instructions, regular monitoring and follow up and positive feedback to encourage exercises. Using such communication skills to develop a professional bonding with the patient not only enhances the therapeutic relationship, but also addresses other determinants such as patient’s understanding of condition, providing a positive experience of physiotherapy and enhancing active engagement of the patient with the therapy process. It has also been shown to be related to how patients experience their condition.
Previous research from a variety of healthcare settings has indicated that 50% of psychosocial problems and concerns of the patients are missed by healthcare practitioners due to lack of clear communication. It is vitally important, then, for health professionals to openly discuss patients’ beliefs and perceptions with them, help them feel comfortable expressing their concerns and respectfully address their confusions, misgivings and apprehensions about treatment. However, it has been shown that although many simple and complex strategies have been suggested and investigated with at best modest effects, as a profession weIl have not adequately adopted a biopsychosocial orientation to our practice. Until our educational practices, departmental policies, training habits and clinical practices change to support better bio-psychosocially orientated practice and enhanced therapeutic relationships poor rehabilitation adherence is likely to continue being a problem.
There has been a tendency to focus on the individual patient characteristics such as age, gender, education level, employment status, occupation, marital status, number of children and income as determinants of rehabilitation adherence. The findings from my project indicate that these factors are not a major influence on rehabilitation adherence; even in studies which have found correlation between these factors and adherence, the effect is small and may be overcome by tailoring the education to the patient’s level of understanding.
Therefore it is important that physiotherapists do not approach patients with negative attitude based on these stereotypes.
While therapeutic relationship reflects a bonding between a patient and the physiotherapist, departmental managers and policy makers have an equally important role to play in facilitating this relationship. Due to cost cutting in the NHS, there has been increasing pressure on physiotherapists to reduce the session duration and the overall number of sessions. Physiotherapists are increasingly being measured against patient discharge from the services. This can negatively impact not only on the therapeutic relationship but also clinical outcomes and patient satisfaction which may have secondary impact on rehabilitation adherence. There is a need for commissioners to undertake an assessment of the physiotherapy services being delivered in their area and their impact on reducing the burden of musculoskeletal disease to ensure appropriate funding is provided to deliver optimal treatment outcomes.
Departmental managers can also help facilitate therapeutic relationship by ensuring that appointments are running on time and that there is a clean, relaxed and welcoming environment in the waiting areas. These measures may help patients feel valued and cared for within the physiotherapy department. Patient communication with the physiotherapist can also be enhanced by addressing any confidentiality concerns which emanate from use of curtained cubicles and shared treatment areas.
Effective communication skills are essential for correctly and proficiently gathering information in physiotherapy sessions as well as for addressing the needs and concerns of patients. Considering the cultural, language and socio-economic diversity of patients and physiotherapists, teaching clinical communication skills must occupy a central position in undergraduate training curricula. While most universities in United Kingdom cover aspects of communication training within their undergraduate curriculum, a survey highlighted that there is need for designing training to be primarily experiential rather than lecture based; and assessing students’ actual performance rather than using written assessments for evaluation.
The findings from my research underline the importance of having a therapist who listens to patients, trusts them, and uses a patient-centred approach. It involves a physiotherapist providing a meaningful rationale for the treatment approach being provided and acknowledging the patient’s feelings and perspectives, appropriate short and long term goals relevant to the patient and autonomy supportive behaviour which encourages patient’s independent decision making. Such proactive approaches by physiotherapists may enhance the patients’ understanding of the condition and treatment being offered, influence perceived need and may facilitate prioritisation of their physiotherapy program over other social obligations. Thus a positive therapeutic relationship is a thread which weaves through the fabric of rehabilitation adherence and influences not only the patient-therapist interaction, but also several other psychosocial determinants to facilitate greater rehabilitation adherence.
Acknowledgement: The above article is based on the findings of my PhD study titled – “Determinants of rehabilitation adherence in musculoskeletal physiotherapy: A mixed methods project” funded by Sheffield Hallam University, United Kingdom (2011-2015)