Behavioural Mechanisms Guiding Orthopaedic Treatment Success
To a large extent, the effectiveness of physio-therapy prescriptions relies on repetition, which, in turn, depends on patient adherence.
While many studies fail to measure patient adherence, many more do, but few explore the mechanisms of patient adherence. In February, Lianne Wood and colleagues from universities throughout Australia, the United Kingdom, and Canada published an enlightening study in the British Journal of Sports Medicine. Applying an intensive research technique to 75 peer-reviewed trials regarding persistent back pain, they sought to statistically elucidate behaviour-al mechanisms that create changes in patient outcomes related to adherence, engagement, and clinical success. While this study focuses on physiotherapy for back pain, the mechanisms quickly reveal themselves as relevant to pa-tient adherence across a broad spectrum of diagnoses and healthcare settings.
The research identified specific clinician behaviours that can be statistically tracked as mechanisms supporting or eroding trust, moti-vation, and confidence, all of which combine to determine the adherence level and, ultimately, clinical success. Findings with statistically mod-erate to high confidence include:
• Clinicians who take time to explore and understand the patients’ beliefs and fears have greater rapport, resulting in greater trust.
• Holistic assessments build trust by making a patient feel heard and understood.
• When clinicians provide specific explana-tions tailored to the patient’s beliefs and fears, trust and reassurance are built.
• Clinicians attempt to reconcile unhelpful beliefs and build trust.
• Collaboration in the therapeutic planning and relationship builds trust.
• When clinicians prescribe holistic, individual-ised treatment plans, adherence rises.
• Regular feedback provided by the clinician facilitates trust through the development and maintenance of a therapeutic alliance, which also bolsters engagement.
• Timely monitoring and follow-up increase motivation and adherence.
• Individualised support to help patients fit adherence into their daily routines improves motivation and adherence.
• Providing therapeutic exercise that patients feel is attainable and enjoyable improves motivation and adherence, and the converse is also true.
• When patients have the opportunity to perform exercises with a clinician present, AND there is individual correction, OR pro-gression in the exercise is prescribed, this increases confidence.
Many of the practices described have long been considered in terms of their physiological impact, rather than in terms of their behaviour-al effects. We are encouraged by the fact that, at Advanced Physiotherapy, many of these positive practices are part of our compa-ny culture and our routine physiotherapy: holistic assessment, individualised and holistic treatment plans, regular feedback, active clinician supervision, timely monitoring & follow-up, and attainable & progressive goals. We are additionally encouraged by apparent opportunities to further operationalise behav-ioural mechanisms that ultimately lead to improved outcomes.
Reference:
1. Wood L, Foster NE, Dean SG, Booth V, Hayden JA, Booth A. Contexts, behavioural mechanisms and out-comes to optimise therapeutic exercise prescription for persistent low back pain: a realist review. British Journal of Sports Medicine. 2024 Feb 1;58(4):222-30.