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Effects of Interventions to Improve Individual’s Adherence to Exercise Programs in people with Chronic.. Bickerstaffe, Jane; Chatwin, Cheryl; Corrigan, Lindsey; DePape, Christine; MacPherson, Katie; Richardson, Kate; Thibert, Steph 2010-07-31

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Effects of Interventions to Improve Individual’s Adherence to Exercise Programs in People with Chronic DiseaseRESEARCHERS:Jane Bickerstaffe, Cheryl Chatwin, Lindsey Corrigan, Christine De Pape, Katie MacPherson, Kate Richardson, and Stephanie ThibertSUPERVISOR:Linda LiBackground InformationCVD is the primary cause of death in Canada [1]By 2030 COPD will be 3rd leading cause of death world wide [1]9.3% US population suffers from diabetes mellitus, of which 90% have Type II Diabetes [2]Benefits of Physical ActivityType II DM: regulates glucose levels [2]COPD: reduces risk of exacerbations, improves ventilation & strengthens respiratory muscles [3]Osteo- and Rheumatoid arthritis: maintain full joint excursion [4]Poor AdherencePoor adherence is associated with a reduction in treatment effectiveness leading to poorer health [5]~30-60% patients fail to adhere [6]The cost of treating non-adherent patients exceeds that afforded to the treatment of adherent patients [5]RationaleMany studies have investigated barriers to exercise adherence or predictors of patient adherenceLimited research focusing on ways to increase patient adherenceResearch QuestionPrimary Question:Are interventions aimed at improving exercise adherence effective in people living with a primary diagnosis of one or more of the following common chronic conditions: Ischemic Heart Disease, Hypertension, Type II Diabetes, Rheumatoid Arthritis, Osteoarthritis, or Chronic Obstructive Pulmonary Disease?Secondary Question:Are there tools aimed at increasing exercise adherence that are superior to others in maintaining lifelong patient compliance?MethodsSearch StrategyConditionsType II DiabetesHypertensionChronic Obstructive Pulmonary DisorderEmphysemaCoronary DiseaseCardiovascular DiseaseRheumatoid ArthritisOsteoarthritisAdherenceAdherenceComplianceMotivationGuideline AdherenceExerciseExercisePhysical ActivityWalkingDatabase SearchPsychINFOCochrane Database of  Systematic ReviewsWeb of ScienceGoogle ScholarMEDLINECINAHLEMBASEPEDroSport DiscusPubMedPeriod of time searched:1950 – November 29, 2009Study SelectionInclusion CriteriaAdults >18 years oldDiagnosed with a common chronic condition:Hypertension, Type II Diabetes, COPD, Ischemic Heart Disease, Osteoarthritis or Rheumatoid arthritisPrescribed an exercise program or physical activity guidelines Adherence intervention >1monthCompares one adherence intervention to another or to a controlStudy includes adherence as an outcome measureStudy SelectionExclusion CriteriaNot published in EnglishAnimal studiesCase StudyUnderlying pathology that would restrict ability to adhere to or participate in a physical activity programQuality AssessmentPEDro Scale (11 categories)Low quality < or equal to 3 Moderate quality = 4 or 5 High Quality > or equal to 6  Oxford Center for Evidence-based Medicine Levels of EvidenceRated as either 1b or 2bOn Average, the quality of articles are rated as HIGHMean score of 6/11ResultsSelf Mediated ApproachesAccountabilityDiaryEmpowermentMediaSelf Mediated ApproachesAccountability – (2 articles) [7-8]Statistically significant increases in adherence with use of diary to record physical activityEmpowerment – (3 articles) [9-11]Videos (patient interviews; motivation/exercise; correct body mechanics in video,  audio & written) Patient interviews & motivation/exercise videos showed statistically significant increases in adherence ratesBody mechanics audio, video, & written saw a trend towards decreased adherence in all groupsPractitioner Mediated ApproachesIntentContractsFacilitationCounsellingTelephoneFace-to-FaceGMCBActionExercise groupPractitioner Mediated ApproachesIntent (1 article) [12]15 of 63 would not sign contractSigned vs. not signed: 65% vs 20% adherence rateAction (2 articles) [13-14]Home vs home + group sessions: No evidence of increased compliance with home programGroup vs individual: At 12 mos: 37% control group & 44% intervention group still participating Of these 75% of control vs 68% intervention groups adhering to programPractitioner Mediated ApproachesTelephone Counselling (6 studies) [2,15-19]2–18 phone calls lasting up to 30 minutesStatistically significant changes or a trend towards positive changes in adherence in all studiesFace-to-face counselling (3 studies) [20-22]With spouse/partner, 1:1 or group counselling1–10 sessions from 10-90 minutes per sessionPositive changes in adherence in all studies, 2 showed statistical significanceGroup Mediated Cognitive Behavioural Therapy  (4 articles) [23-26]4-20 sessions x 20-60 minute per sessionA statistically significant or a trend towards increased exercise adherence rates in GMCB intervention groupsFacilitation (13 articles)Multi-Faceted ApproachesAll included counselling in combination with an additional interventionMediaDiaryPedometerMulti-Faceted ApproachesMedia (1 article) [27]30 min session with 5 f/u sessions + written physical activity & nutritional information vs usual careArticle found a trend towards increased exercise adherenceDiary (2 articles) [28-29]3 vs 4 month interventionArticles found a statistically significant or a trend towards positive change in adherencePedometer (3 articles) [30-32]4-5 sessions over 8-18 weeksArticles found a statistically significant or a trend towards positive change in exercise adherenceResults27 articles based on 26 trials26 demonstrated positive adherence changes with an adherence intervention tool14 studies showed statistically significant increases in adherence 1 study showed a non-statistically significant decreased adherence trendDiscussionIndividual Mediated StrategiesAccountabilityDiaries [7-8]Offer accountabilitySelfPractitioner Produced good short-term and long-term effectsIndividual Mediated StrategiesEmpowermentMedia [9-11]Information empowers good decision makingNo one form appeared superior Timing of delivery had no notable effectNo long-term dataPractitioner Mediated StrategiesIntentContracts [12]Trend toward increased adherenceLow standard for adherenceResults may present biasPractitioner Mediated Strategies Short-Term Showed stronger evidence for increasesLong-TermDemonstrated increases, reduced from short-termFollow up study reinforced this trend6 monthsPoint at which trials split from statistically significant to non-statistically significantFacilitation  Counselling [2, 15-22]Practitioner Mediated StrategiesAll showed trends toward increased adherenceShort-TermIncreases not as strong compared to long-termLong-TermStrong evidence for increasing adherenceAll self report measuresFacilitationGroup Mediated Cognitive Behavioural Focus [23-26]Practitioner Mediated StrategiesActionGroup Exercise Class [13-14]High drop-out ratesTrend toward increased adherenceMulti Faceted Approaches Counselling PLUS [27-32]MediaDiaryPedometerAll combinations helped to increase adherenceNo one combination is superior to the nextCombining strategies is more effective than a single strategyLimitations of ResearchPoor comparability between studiesNo standard definition or measurement for adherenceNo standard for outcome measuresMany self-reportPoor generalizability of resultsSparse long-term follow up dataConclusionImplications for PracticeAdherence intervention tools have a positive effect on client adherence Any strategy is more effective than noneMake adherence a focus of patient programsConsider patient preferenceType of tool appears to be of little importanceConsider client preferenceImplications for ResearchAdherence definition & measure is not consistentMore research is needed:Larger sample sizesMulti-site trialsBetween group analysesIntervention toolsDisease populationsExpand intervention tools repertoireLong-term follow upInvestigator’s RecommendationsINSERT FORMATTED TABLEAcknowledgments Special Thanks Our Supervisor Linda LiAlso:Darlene ReidElizabeth DeanCharlotte BeckDean GuistiniQuestionsReferencesWorld Health Organization. World Health Statistics 2008 [Internet]. 2008 [cited 2009 July 19 ]. Available from http://www.who.int/whosis/whostat/EN_WHS08_Full.pdfSacco WP, Malone JI, Morrison AD, Friedman A, Wells K. Effect of a brief, regular telephone intervention by paraprofessionals for type 2 diabetes. J Behav Med. 2009; 32(4): 349-359.Public Health Agency of Canada. I have COPD. Why is it important for me to exercise? [Internet]. 2008 [updated 2008 Jul 10; cited 2009 July 19]. Available from http://www.phac-aspc.gc.ca/cd-mc/crd-mrc/copd_exercise-mpoc_exercice-eng.phpThe Arthritis Society. Exercise and Mobility: Use It or Lose It [Internet]. 2008 [updated 2008 Feb 23; cited 2010 Jul 21]. Available from:  http://www.arthritis.ca/tips%20for%20living/exercise/use%20it%20or%20lose%20it/default.asp?s=1&province=caBosch-Capblanch X, Abba K, Prictor M, Garner P. Contracts between patients and healthcare practitioners for improving patients’ adherence to treatment, prevention and health promotion activities. Cochrane Database of Systematic Reviews [Internet] 2007 [cited 2009 Jul 10]. Available from: http://research-archive.liv.ac.uk/662/1/CD004808.pdfRoter DL, Hall JA, Merisca R, Nordstrom B. Effectiveness of Interventions to Improve Patient Compliance: A Meta-Analysis. Med Care. 1998; 36(8): 1138-1161.Arrigo I, Brunner-LaRocca H, Lefkovits M, Pfisterer M, Hoffmann A. Comparative outcome one year after formal cardiac rehabilitation: The effects of a randomized intervention to improve exercise adherence. Eur J Cardiovasc Prev Rehabil. 2008; 15(3): 306-311.van den Berg MH, Ronday HK, Peeters AJ, le Cessie S, van der Giesen FJ, Breedveld FC, Vliet Vlieland TP. Using Internet Technology to deliver a Home-based Physical Activity Intervention for Patients with Rheumatoid Arthritis: A Randomized Controlled Trial.  Arthritis Rheum. 2006; 55(6):935-45.Petty TL, Dempsey EC, Collins T, Pluss W, Lipkus I, Cutter GR, Chalmers R, Mitchell  A, Weil KC. Impact of customized videotape education on quality of life in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil. 2006; 26(2): 112-117.Mahler HI, Kulik JA, Tarazi RY. Effects of a videotape information intervention at discharge on diet and exercise compliance after coronary bypass surgery. J Cardiopulm Rehabil. 1999; 19(3): 170-177.Schoo AM, Morris ME, Bui QM. The effects of mode of exercise instruction on compliance with a home exercise program in older adults with osteoarthritis. Physiotherapy. 2005; 91(2): 79-86.Oldridge, N. B., & Jones, N. L. Improving patient compliance in cardiac exercise rehabilitation: Effects of written agreement and self-monitoring. Eur J Cardiovasc Prev Rehabil. 1983; 3(4): 257-262.McCarthy CJ, Mills PM, Pullen R, Richardson G, Hawkins N, Roberts CR, Silman AJ, Oldham JA. Supplementation of a home-based exercise programme with a class-based programme for people with osteoarthritis of the knees: A randomised controlled trial and health economic analysis. Health Technol Assess. 2004;8(46):iii-iv, 1-61.Praet SF, van Rooij ES, Wijtvliet A, Boonman-de Winter LJ, Enneking T, Kuipers H, C. Stehouwer CA, and van Loon LJ. Brisk walking compared with an individualised medical fitness programme for patients with type 2 diabetes: A randomised controlled trial. Diabetologia. 2008; 51(5): 736-746.Steele BG, Belza B, Cain KC, Coppersmith J, Lakshminarayan S, Howard J, Haselkorn JK. A randomized clinical trial of an activity and exercise adherence intervention in chronic pulmonary disease. Arch Phys Med Rehabil. 2008; 89(3): 404-412.Yates BC, Anderson T, Hertzog M, Ott C, Williams J. Effectiveness of follow-up booster sessions in improving physical status after cardiac rehabilitation: Health, behavioral, and clinical outcomes. Appl Nurs Res. 2005; 18(1): 59-62ReferencesDi Loreto C, Fanelli C, Lucidi P, Murdolo G, De Cicco A, Parlanti N, Santeusanio F, Brunetti P, De Feo P. Validation of a counseling strategy to promote the adoption and the maintenance of physical activity by type 2 diabetic subjects. Diabetes Care, 2004; 26(2): 404-408.Kirk, AF, Mutrie N, Macintyre PD, Fisher MB. Promoting and maintaining physical activity in people with type 2 diabetes. Am J Prev Med. 2004; 27(4): 289-296. Mildestvedt T, Meland E, Eide GE. How important are individual counselling, expectancy beliefs and autonomy for the maintenance of exercise after cardiac rehabilitation?. Scand J Public Health. 2008 Nov;36(8):832-40.Dracup K, Meleis AI, Clark S, Clyburn A, Shields L, Staley M. Group counseling in cardiac rehabilitation: Effect on patient compliance. Patient Educ Couns. 1984; 6(4):169-177.Kirk AF, Higgins LA, Hughes AR, Fishert BM, Mutrie N, Hillis S, MacIntyre PD. A randomized, controlled trial to study the effect of exercise consultation on the promotion of physical activity in people with type 2 diabetes: A pilot study. Diabet Med. 2001; 18(11): 877-882.Martinus R, Corban R, Wackerhage H, Atkins S, Singh J. Effect of psychological intervention on exercise adherence in type 2 diabetic subjects. Ann N Y Acad Sci. 2006; 1084: 350-360.Carlson JJ, Johnson JA, Franklin BA, VanderLaan, RL. Program participation, exercise adherence, cardiovascular outcomes, and program cost of traditional versus modified cardiac rehabilitation. Am J Cardiol. 2000; 86(1): 17-23. Carlson JJ, Norman GJ, Feltz DL, Franklin BA, Johnson JA, Locke SK. Self-efficacy, psychosocial factors, and exercise behavior in traditional versus modified cardiac rehabilitation. J Cardiopulm Rehabil. 2001; 21(6): 363-373.Focht BC, Brawley LR, Rejeski WJ, Ambrosius WT. Group-mediated activity counseling and traditional exercise therapy programs: Effects on health-related quality of life among older adults in cardiac rehabilitation. Ann Behav Med. 2004; 28(1): 52-61.Rejeski WJ, Brawley LR, Ambrosius WT, Brubaker PH, Focht BC, Foy CG, Fox LD. Older adults with chronic disease: Benefits of group-mediated counseling in the promotion of physically active lifestyles. Health Psychol. 2003; 22(4): 414-423Clark M, Hampson SE, Avery L, Simpson R.  Effects of a tailored lifestyle self-management intervention in patients with type 2 diabetes. Br J Health Psychol. 2004; 9(3): 365-379.Liebreich T, Plotnikof RC, Courneya KS, Boule N. Diabetes NetPLAY: A physical activity website and linked email counselling randomized intervention for individuals with type 2 diabetes. Int J Behav Nutr Phys Act. Activity. 2009; 6: 18.Sniehotta FF, Scholz U, Schwarzer R, Fuhrmann B, Kiwus U, Voller H. Long-term effects of two psychological interventions on physical exercise and self-regulation following coronary rehabilitation. Int J Behav Med. 2005; 12(4): 244-255.Hospes G, Bossenbroek L, ten Hacken NH, van Hengel P, de Greef, MH. Enhancement of daily physical activity increases physical fitness of outclinic COPD patients: Results of an exercise counseling program. Patient Educ Couns. 2009; 75(2): 274-278.de Blok BM, de Greef MH, ten Hacken NH, Sprenger SR, Postema K,  Wempe JB. The effects of a lifestyle physical activity counseling program with feedback of a pedometer during pulmonary rehabilitation in patients with COPD: A pilot study. Patient Educ Couns. 2006; 61(1): 48-55.Butler L, Furber S, Phongsavan P, Mark A, Bauman A. Effects of a pedometer-based intervention on physical activity levels after cardiac rehabilitation: A randomized controlled trial. J Cardiopulm Rehabil Prev. 2009; 29(2): 105-114. Steph*Steph**StephCOPD: Lungs & Resp ms: for improved ventilation and respiratory functionOS & RA: maintains full joint excursion, thereby limiting the contraction, stiffening & weakening of pain sensitive soft tissues supporting the joints*StephEstimated 30-60%of patients prescribed therapeutic interventions fail to adhere to their programSteph*StephDo we want to expand on this….include flow chart*Steph*Steph*Steph*Pedro – used all 11 points on the scaleSteph*Statistical analysis and  formal testing of homogeneity was not appropriate . Therefore, we completed a narrative summary of the main findings.  In order for us to do this systematically, the interventions were mapped into three main categories.  There is no given framework available to classify the different interventions that aim to increase adherence, investigators grouped the interventions into their own categories and subsequently into subcategories. Consensus was achieved by discussion between the us27 articles – explain results to you the simplest way. If you find yourself confused along the way I’ll be giving a brief summary at the end.*Interventions classified as self-mediated approaches are those which do not require the presence or guidance of a HCP and, thus, can be carried out independently by the patient. This category can be further divided into interventions that provide the patient with feedback, for example exercise diaries, and those that simply provide the patient with information or knowledge*Dutch guidelines 30 min 5x/week at moderate intensity OR 20 min vigorous 5 days/weekAccountability – DIARYArrigo – exercise in cardiac rehab pts vs usual care (73 v 40% adhered) *p<0.0005 at 12 mosVan den Berg – RA pts meeting Dutch guidelines (35% vs 11%) *p=0.001 at 9 monthsEmpowerment – MEDIA – all compared to usual careMahler – videotape (mastery vs coping) post CABG 12 wks*coping vs mastery & usual care p<0.02* & p<0.04*Petty – videotape (customized vs standard) 16 wks COPDSchoo – audiotape vs videotape 8 wks knee/hip OAKatieThe interventions included in practitioner-mediated approaches can be analyzed based on the stage at which the intervention contributes to the participant’s exercise behaviors. Intent Facilitation Action.Interventions that target the intent stage are tools that the health care practitioner implements to assist the client in declaring what they intend to do. (ie. Contracts: client is intending to begin an exercise program )target facilitation are actions that allow the client to participate in an adherence regime as part of an active partnership with the HCP. The most common form of this is counseling. Typically includes information, goals, skills training, barrier identification, and problem solving.GMCB: encouraging increased personal responsibility for exercise and decreased dependency on the clinic the spectrum is action, this category refers to strategies that place action in the hands of the client. Accountability plays a role but it is external to the client and is seen in examples like group programming whereby the client has a facility for exercise available, they just need to take action to make themselves physically present.*Intent – CONTRACTSOldridge cardiac rehab contract to adhere to program for 6 mos, 15 of 63 would not sign. Signed vs. not signed: 65% vs 20% adherence rateThe intervention group was to sign a contract.Action: group vs individualMcCarthy: daily home program vs daily home program + 2 x 45min sessions / week x total of 8 weeksRESULTS: no evidence compliance with home program was different b/t groupsPraet: 3 x 60 min group sessions per week for 9 mos vs 90min/week (3 x 30 min) individual sessions gradually increased to 180 – 225 min/wk over 6 mos RESULTS: After 12 months, 18 (37%) brisk walking and 19 (44%) medical fitness participants respectively were still actively participating with mean adherence levels of 75±16% and 68±13% (p>0.05)FacilitationTelephone Counselling (sacco, yates, steele, kirk (2004), mildsvedt, di loreto)Face-to-face counselling (Dracup, kirk (2001) & martinus) – be more clearDracup w/ spouse: incr adherence w/ spouse, decr w/out spouse & w/out counsellingKirk 2001: stat sig incr # steps/wk, trend to incr 7day recallMartinus: stat sig b/t grps higher attendance rate intervention vs controlGMCB:Carlson: 20 x 60 minutes sessionsRejeski: 19 x 20-25 min sessionsFocht: 4 x 25 min sessionsKatieInterventions classified as multi-faceted are those that combine self-mediated and practitioner-mediated approaches. Each of the studies in this category utilized counseling as itspractitioner-mediated component, and one of three interventions as its self-mediated component – pedometers, exercise logs or informational media.*Media (Clark)30 min face-to-face counselling (goal setting & self-management skills) + 5 f/u (phone call or face-to-face) over 6 mos + written info on nutrition & physical activityRESULTS: Trend towards small increase in physical activity vs control Diary (Liebrich & Sniehotta)Liebrich: weekly exercise counseling + log bookRESULTS: stat sig incr # minutes physical activity vs controlSniehotta: counseling (self-manag’t plan) + diaryRESULTS: trend towards higher exercise rates vs controlPedometer (Hospes, de Blok & Butler)Hospes: 5 counseling sessions ( goal-setting) over 12 wksRESULTS: stat sig higher daily step counts vs control groupDe Blok: 4 counseling sessions over 8 wksRESULTS: trend towards higher daily step counts vs control groupButler: 4 phone call counseling sessions over 18 wksRESULTS: at 6 mos stat sig increase mean minutes physical activity vs control groupKatie10 statistically significant positive trends11 trials showed non-statistical positive trends4 trials show both statistical significant and non-statistical significant positive trends*ADD blurb on IMA dichotomy descriptionOnly one of the 3 media interventions produced a statistically significant result; furthermore, this result was obtained only 3 months after the intervention was implemented.  There were no follow-ups beyond 4 months both exercise log studies, Arrigo et al (YEAR) and Vandenberg et al (YEAR), reported statistically significant results 1 year after the intervention was implemented, indicating that not only were the interventions effective at increasing adherence to exercise in the short term, but in the long term as wellother types of interventions that offer accountability, for example the “buddy system”, could be studied *ADD blurb on IMA dichotomy descriptionOnly one of the 3 media interventions produced a statistically significant result; furthermore, this result was obtained only 3 months after the intervention was implemented.  There were no follow-ups beyond 4 months both exercise log studies, Arrigo et al (YEAR) and Vandenberg et al (YEAR), reported statistically significant results 1 year after the intervention was implemented, indicating that not only were the interventions effective at increasing adherence to exercise in the short term, but in the long term as wellother types of interventions that offer accountability, for example the “buddy system”, could be studied *interventions included in practitioner-mediated approaches can be analyzed based on the stage at which the intervention contributes to the participant’s exercise behaviors. The stages can be considered as a spectrumtrend towards increased adherence was demonstrated, the study employed a relatively low standard for adherence and the increase in adherence was not found to be statistically significant.*spectrum had the most amount of research available. All interventions in this portion involved some form of counselling, however, the focus and the method of delivery of the counselling differedThe various modes of delivery included face to face individual counselling, face to face group counselling, and individual phone calls. It should be noted that the author’s could not find an association between a particular delivery method of counselling and statistical significance. All statistically significant results for counseling were found in trials that were less than or equal to six months in duration, with the exception of Rejeski. Though Rejeski’s study is worth noting for the statistically significant increases in adherence over a long term trial, the decision to employ self report adherence measures and not blind subjects are factors that should be considered, as they can arguably affect the strength of the findings. Regardless of this one exception, it appeared as though adherence interventions implemented over long term trials had a tendency to increase adherence, but did yield statistically significant results. This was most notably demonstrated in Steele’s study, where statistically significant short term adherence increases were recorded, yet during a long term follow up of the same participants the adherence was no longer at a level of statistical significance. Further observation of the trial characteristic for counseling interventions revealed six months to be the duration of time at which studies began to split between having statistically significant results and not. Short term studies conducted over less than six months demonstrated very favorable results, all of which demonstrated statistically significant increases in adherence. These findings indicate that a counseling intervention may be an effective means of increasing exercise adherence when implemented over a duration of six months or less.One of the challenges with the interpretation of the information we found for these studies was that there was no homogeneity between the prescription of frequency, intensity, and duration of counseling sessions given. Regardless, it appears that some prescription of counseling proves to have a positive effect on increasing adherence as compared to receiving no counseling.*GMCB is a focus that is put on counselling sessions, that focuses on role identification ADDstudies that utilized a group mediated cognitive behavioral (GMCB) focus to their counseling approach. Four studies looked at the GMCB approach, all of which showed a trend toward increased participant adherence rates when compared to participants that received no counseling.  Of the four trials, the three studies that were greater than six months in duration had statistically significant increases in adherence as compared the shorter term three month study which did not yield statistically significant results. It should be mentioned however, that all studies found to be statistically significant in the GMCB counseling trials used self report adherence measures, and the study that did not report statistical significance used percentage of sessions attended as an adherence measure.*looked at using a group exercise program as a way of increasing adherencethat the study looking at a diabetes population yielded greater increases in adherence than the study focused on an osteoarthritis population. Many variables can be speculated to be responsible for this difference and further research on disease populations and subsequent group exercise interactions would be merited. *It appears that no combination of tools seems to increase adherence more than othersTalk about…SMA + PMAcombining strategies is more effective at increasing adherence to exercise than using a single strategy on its ownFour out of the six studies that used multi-faceted approaches showed a statistically significant improvement.  At 71%, the multi-faceted approach showed a much higher success rate than either the practitioner- or individual-mediated interventions, indicating that perhaps targeting more than one domain in an intervention is more effective at increasing adherence than targeting only one. ADD IN LONG TERM = NOT STRONG FINDING*There is a wide array of interventions examined in the included articles; however, with the exception of counseling, none have been studied by more than a few authors.  Within these few articles examining each intervention, there is no standard protocol for the intervention and, thus, it differs in each study; furthermore, the chronic condition that is involved is different from study to study.  As such, there is very little evidence regarding the effects of each particular intervention on adherence in patients with a particular chronic condition; therefore, it is difficult to make any firm recommendations regarding which intervention is most effective, as well as how and with whom to implement it.is the variation in the definition and measurement of adherence amongst them.  9 of the 27 articles in this review do not define adherence and, amongst those that do, there is gross dissimilarity.  Used either % session attended or number of exercise per week, or pedometer. Although many chose to define adherence by the amount of activity fulfilled in a day or week, there was no consistency in the defined minimum amount, if any was stated. A standard definition of adherence to exercise is required in order to meaningfully compare studies that intend to improve it. the outcome measures used to assess adherence are also highly variable amongst the included studiesGeneralizability poor. Often times included bc they were already a oartof a rehab program. Older age population 48.6 to 70.4 years old **StephIt is our belief that the topic of increasing adherence in our patient population is of greatimportance as it is a challenge we are constantly faced with our clientele and is extremely relevant to ourpractice in the clinical setting. From our review of this topic it appears as though there is not one strategythat is more effective than another, but any strategy is more effective than none. It is our recommendationwithin the clinic that practitioners make adherence a focus of their patient programs and create some typeof accountability with their patients to adhere to program prescription. Though this may take longer in theshort term, it will provide a benefit that is better and more sustainable for patient care. Whether, by phonecalls, or diaries, education sessions, or group programs it is in our patient’s, our practices’, and ourprofessional best interest to prescribe an adherence tool along with our prescribed exercise program inorder to better positively affect our client’s health and rehabilitation.*StephIn the development of this review we struggled to find high quality articles that had enoughsimilarities to draw comparisons based on their results. It is our suggestion that further research beconducted in the area of interventions to increase adherence to exercise programs using larger samplesizes, multi site trials, between group analyses, and long term follow up data records. Furthermore, it isimperative that a gold standard for the definition and measurement of adherence be defined as a templatefor further investigations of adherence interventions. Finally, it would also be worthwhile to have a multigroup study looking at identical study variables with different adherence interventions to determine if oneintervention is superior to another at increasing adherence.Stephrepresents the personal opinion of the authors only. Due to a lack of evidence and study comparability no one strategy for increasing adherence can be confidently deemed the most effective. This table is merely a summary of the recommendations we would make for our own practice based on the literature we have reviewedexercise logs, when compared to media interventions, are the clear choice in terms of increasing a patient’s adherence to exercise, we cannot make any definitive conclusions.  With only 2 and 3 studies in each group, we do not have the evidence to strongly recommend one type of intervention over the other, especially as all of the interventions in each group were very different from each otherIt appears from these results that accountability is a more critical component to an intervention that aims to increase adherence than is empowerment. Though a trend towards increased adherence was demonstrated, the study employed a relatively low standard for adherence and the increase in adherence was not found to be statistically significant. Furthermore, the study was graded as achieving only a moderate quality score. Therefore it is our opinion that the use of contracts as a sole intervention tool to increase exercise adherence would not be the most effective choice for practitioners.  Short term studies conducted over less than six months demonstrated very favorable results, all of which demonstrated statistically significant increases in adherence. These findings indicate that a counseling intervention may be an effective means of increasing exercise adherence when implemented over a duration of six months or less.indicate that when choosing a counseling technique for long term program adherence, counseling with a GMCB focus may be most beneficial. INSERT INFO ON TABLE FOR ACTIONAt 71%, the multi-faceted approach showed a much higher success rate than either the practitioner- or individual-mediated interventions, indicating that perhaps targeting more than one domain in an intervention is more effective at increasing adherence than targeting only one. Interventions should be used for adherence post  rehabilitation program. Possibly bc during the pt figures they are already doing rx with youÉÉÉ*KatieWe would like to acknowledge our supervisor Linda Li for her contributions to this review, and would like to thank her for her support, advice, and guidance during the development of this report. We would also like to thank…as they have each contributed in various forms to this review**Katie Effects of Interventions to Improve Individual’s Adherence to Exercise Programs in People with Chronic Disease RESEARCHERS: Jane Bickerstaffe, Cheryl Chatwin, Lindsey Corrigan, Christine De Pape, Katie MacPherson, Kate Richardson, and Stephanie Thibert SUPERVISOR: Linda Li  Background Information    CVD is the primary cause of death in Canada [1]    By 2030 COPD will be 3rd leading cause of death world wide [1]    9.3% US population suffers from diabetes mellitus, of which 90% have Type II Diabetes [2]  Benefits of Physical Activity    Type II DM: regulates glucose levels    COPD: reduces risk of exacerbations, improves ventilation & strengthens respiratory muscles [3]    Osteo- and Rheumatoid arthritis: maintain full joint excursion [4]  [2]  Poor Adherence    Poor adherence is associated with a reduction in treatment effectiveness leading to poorer health [5]    ~30-60% patients fail to adhere [6]    The cost of treating non-adherent patients exceeds that afforded to the treatment of adherent patients [5]  Rationale    Many studies have investigated barriers to exercise adherence or predictors of patient adherence    Limited research focusing on ways to increase patient adherence  Research Question Primary Question: Are interventions aimed at improving exercise adherence effective in people living with a primary diagnosis of one or more of the following common chronic conditions: Ischemic Heart Disease, Hypertension, Type II Diabetes, Rheumatoid Arthritis, Osteoarthritis, or Chronic Obstructive Pulmonary Disease? Secondary Question: Are there tools aimed at increasing exercise adherence that are superior to others in maintaining lifelong patient compliance?  Methods  Search Strategy    Adherence • Adherence • Compliance • Motivation • Guideline Adherence    Exercise • Exercise • Physical Activity • Walking    Conditions • Type II Diabetes • Hypertension • Chronic Obstructive Pulmonary Disorder • Emphysema • Coronary Disease • Cardiovascular Disease • Rheumatoid Arthritis • Osteoarthritis  Database Search        MEDLINE CINAHL EMBASE PEDro Sport Discus PubMed       Period of time searched: 1950 – November 29, 2009  PsychINFO Cochrane Database of Systematic Reviews Web of Science Google Scholar  Study Selection Inclusion Criteria • Adults >18 years old • Diagnosed with a common chronic condition:  Hypertension, Type II Diabetes, COPD, Ischemic Heart Disease, Osteoarthritis or Rheumatoid arthritis Prescribed an exercise program or physical activity guidelines Adherence intervention >1month Compares one adherence intervention to another or to a control Study includes adherence as an outcome measure •  • • • •  Study Selection Exclusion Criteria  • Not published in English • Animal studies • Case Study • Underlying pathology that would restrict ability  to adhere to or participate in a physical activity program  Quality Assessment   PEDro Scale (11 categories)  • Low quality < or equal to 3 • Moderate quality = 4 or 5 • High Quality > or equal to 6    Oxford Center for Evidence-based Medicine Levels of Evidence  • Rated as either 1b or 2b    On Average, the quality of articles are rated as HIGH  • Mean score of 6/11  Results  Self Mediated Approaches    Accountability  • Diary   Empowerment  • Media  Self Mediated Approaches    Accountability – (2 articles) [7-8] • Statistically significant increases in adherence with use of diary to record physical activity    Empowerment – (3 articles) [9-11] • Videos (patient interviews; motivation/exercise; correct body mechanics in video, audio & written) • Patient interviews & motivation/exercise videos showed statistically significant increases in adherence rates • Body mechanics audio, video, & written saw a trend towards decreased adherence in all groups  Practitioner Mediated Approaches    Intent  • Contracts   Facilitation  • Counselling • •  Telephone Face-to-Face  • GMCB   Action  • Exercise group  Practitioner Mediated Approaches   Intent  (1 article)  [12]  • 15 of 63 would not sign contract • Signed vs. not signed: 65% vs 20% adherence rate    Action  (2 articles)  [13-14]  • Home vs home + group sessions: •  No evidence of increased compliance with home program  • Group vs individual: •  At 12 mos: 37% control group & 44% intervention group still participating Of these 75% of control vs 68% intervention groups adhering to program  Practitioner Mediated Approaches Facilitation (13 articles)  • Telephone Counselling (6 studies) • •  [2,15-19]  2–18 phone calls lasting up to 30 minutes Statistically significant changes or a trend towards positive changes in adherence in all studies  • Face-to-face counselling (3 studies) • • •  [20-22]  With spouse/partner, 1:1 or group counselling 1–10 sessions from 10-90 minutes per session Positive changes in adherence in all studies, 2 showed statistical significance  • Group Mediated Cognitive Behavioural Therapy (4 articles) [23-26] • 4-20 sessions x 20-60 minute per session • A statistically significant or a trend towards increased exercise adherence rates in GMCB intervention groups  Multi-Faceted Approaches    All included counselling in combination with an additional intervention  • Media • Diary • Pedometer  Multi-Faceted Approaches   Media (1 article)  [27]  • 30 min session with 5 f/u sessions + written physical •    activity & nutritional information vs usual care Article found a trend towards increased exercise adherence  Diary (2 articles)  [28-29]  • 3 vs 4 month intervention • Articles found a statistically significant or a trend towards positive change in adherence    Pedometer (3 articles)  [30-32]  • 4-5 sessions over 8-18 weeks • Articles found a statistically significant or a trend towards positive change in exercise adherence  Results    27 articles based on 26 trials    26 demonstrated positive adherence changes with an adherence intervention tool    14 studies showed statistically significant increases in adherence    1 study showed a non-statistically significant decreased adherence trend  Discussion  Individual Mediated Strategies    Accountability  • Diaries •  [7-8]  Offer accountability • Self • Practitioner  •  Produced good short-term and long-term effects  Individual Mediated Strategies    Empowerment  • Media •  • • •  [9-11]  Information empowers good decision making No one form appeared superior Timing of delivery had no notable effect No long-term data  Practitioner Mediated Strategies    Intent  • Contracts • • •  [12]  Trend toward increased adherence Low standard for adherence Results may present bias  Practitioner Mediated Strategies Facilitation  • Counselling •  •  • •  [2, 15-22]  Short-Term • Showed stronger evidence for increases Long-Term • Demonstrated increases, reduced from shortterm Follow up study reinforced this trend 6 months • Point at which trials split from statistically significant to non-statistically significant  Practitioner Mediated Strategies Facilitation  •Group Mediated Cognitive Behavioural Focus [23-26] • •  •  All showed trends toward increased adherence Short-Term • Increases not as strong compared to longterm Long-Term • Strong evidence for increasing adherence • All self report measures  Practitioner Mediated Strategies    Action  • Group Exercise Class [13-14] • •  High drop-out rates Trend toward increased adherence  Multi Faceted Approaches    Counselling PLUS • • •      [27-32]  Media Diary Pedometer  All combinations helped to increase adherence No one combination is superior to the next Combining strategies is more effective than a single strategy  Limitations of Research      Poor comparability between studies No standard definition or measurement for adherence No standard for outcome measures  • Many self-report    Poor generalizability of results Sparse long-term follow up data  Conclusion  Implications for Practice   Adherence intervention tools have a positive effect on client adherence    Any strategy is more effective than none    Make adherence a focus of patient programs    Consider patient preference    Type of tool appears to be of little importance  • Consider client preference  Implications for Research    Adherence definition & measure is not consistent    More research is needed:  • Larger sample sizes • Multi-site trials • Between group analyses • •  Intervention tools Disease populations  • Expand intervention tools repertoire • Long-term follow up  Investigator’s Recommendations    INSERT FORMATTED TABLE  Acknowledgments    Special Thanks Our Supervisor Linda Li    Also:  • Darlene Reid • Elizabeth Dean • Charlotte Beck • Dean Guistini  Questions  References                         World Health Organization. World Health Statistics 2008 [Internet]. 2008 [cited 2009 July 19 ]. Available from http://www.who.int/whosis/whostat/EN_WHS08_Full.pdf Sacco WP, Malone JI, Morrison AD, Friedman A, Wells K. Effect of a brief, regular telephone intervention by paraprofessionals for type 2 diabetes. J Behav Med. 2009; 32(4): 349-359. Public Health Agency of Canada. I have COPD. Why is it important for me to exercise? [Internet]. 2008 [updated 2008 Jul 10; cited 2009 July 19]. Available from http://www.phac-aspc.gc.ca/cd-mc/crd-mrc/copd_exercise-mpoc_exercice-eng.php The Arthritis Society. Exercise and Mobility: Use It or Lose It [Internet]. 2008 [updated 2008 Feb 23; cited 2010 Jul 21]. Available from: http://www.arthritis.ca/tips%20for%20living/exercise/use%20it%20or%20lose%20it/default.asp?s=1&province=ca Bosch-Capblanch X, Abba K, Prictor M, Garner P. Contracts between patients and healthcare practitioners for improving patients’ adherence to treatment, prevention and health promotion activities. Cochrane Database of Systematic Reviews [Internet] 2007 [cited 2009 Jul 10]. Available from: http://research-archive.liv.ac.uk/662/1/CD004808.pdf Roter DL, Hall JA, Merisca R, Nordstrom B. Effectiveness of Interventions to Improve Patient Compliance: A Meta-Analysis. Med Care. 1998; 36(8): 1138-1161. Arrigo I, Brunner-LaRocca H, Lefkovits M, Pfisterer M, Hoffmann A. Comparative outcome one year after formal cardiac rehabilitation: The effects of a randomized intervention to improve exercise adherence. Eur J Cardiovasc Prev Rehabil. 2008; 15(3): 306-311. van den Berg MH, Ronday HK, Peeters AJ, le Cessie S, van der Giesen FJ, Breedveld FC, Vliet Vlieland TP. Using Internet Technology to deliver a Home-based Physical Activity Intervention for Patients with Rheumatoid Arthritis: A Randomized Controlled Trial. Arthritis Rheum. 2006; 55(6):935-45. Petty TL, Dempsey EC, Collins T, Pluss W, Lipkus I, Cutter GR, Chalmers R, Mitchell A, Weil KC. Impact of customized videotape education on quality of life in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehabil. 2006; 26(2): 112-117. Mahler HI, Kulik JA, Tarazi RY. Effects of a videotape information intervention at discharge on diet and exercise compliance after coronary bypass surgery. J Cardiopulm Rehabil. 1999; 19(3): 170-177. Schoo AM, Morris ME, Bui QM. The effects of mode of exercise instruction on compliance with a home exercise program in older adults with osteoarthritis. Physiotherapy. 2005; 91(2): 79-86. Oldridge, N. B., & Jones, N. L. Improving patient compliance in cardiac exercise rehabilitation: Effects of written agreement and self-monitoring. Eur J Cardiovasc Prev Rehabil. 1983; 3(4): 257-262. McCarthy CJ, Mills PM, Pullen R, Richardson G, Hawkins N, Roberts CR, Silman AJ, Oldham JA. Supplementation of a homebased exercise programme with a class-based programme for people with osteoarthritis of the knees: A randomised controlled trial and health economic analysis. Health Technol Assess. 2004;8(46):iii-iv, 1-61. Praet SF, van Rooij ES, Wijtvliet A, Boonman-de Winter LJ, Enneking T, Kuipers H, C. Stehouwer CA, and van Loon LJ. Brisk walking compared with an individualised medical fitness programme for patients with type 2 diabetes: A randomised controlled trial. Diabetologia. 2008; 51(5): 736-746. Steele BG, Belza B, Cain KC, Coppersmith J, Lakshminarayan S, Howard J, Haselkorn JK. A randomized clinical trial of an activity and exercise adherence intervention in chronic pulmonary disease. Arch Phys Med Rehabil. 2008; 89(3): 404-412. Yates BC, Anderson T, Hertzog M, Ott C, Williams J. Effectiveness of follow-up booster sessions in improving physical status after cardiac rehabilitation: Health, behavioral, and clinical outcomes. Appl Nurs Res. 2005; 18(1): 59-62  References 1.  2. 3. 4. 5.  6. 7. 8. 9.  10. 11. 12. 13. 14.  15.  16.  Di Loreto C, Fanelli C, Lucidi P, Murdolo G, De Cicco A, Parlanti N, Santeusanio F, Brunetti P, De Feo P. Validation of a counseling strategy to promote the adoption and the maintenance of physical activity by type 2 diabetic subjects. Diabetes Care, 2004; 26(2): 404-408. Kirk, AF, Mutrie N, Macintyre PD, Fisher MB. Promoting and maintaining physical activity in people with type 2 diabetes. Am J Prev Med. 2004; 27(4): 289-296. Mildestvedt T, Meland E, Eide GE. How important are individual counselling, expectancy beliefs and autonomy for the maintenance of exercise after cardiac rehabilitation?. Scand J Public Health. 2008 Nov;36(8):832-40. Dracup K, Meleis AI, Clark S, Clyburn A, Shields L, Staley M. Group counseling in cardiac rehabilitation: Effect on patient compliance. Patient Educ Couns. 1984; 6(4):169-177. Kirk AF, Higgins LA, Hughes AR, Fishert BM, Mutrie N, Hillis S, MacIntyre PD. A randomized, controlled trial to study the effect of exercise consultation on the promotion of physical activity in people with type 2 diabetes: A pilot study. Diabet Med. 2001; 18(11): 877-882. Martinus R, Corban R, Wackerhage H, Atkins S, Singh J. Effect of psychological intervention on exercise adherence in type 2 diabetic subjects. Ann N Y Acad Sci. 2006; 1084: 350-360. Carlson JJ, Johnson JA, Franklin BA, VanderLaan, RL. Program participation, exercise adherence, cardiovascular outcomes, and program cost of traditional versus modified cardiac rehabilitation. Am J Cardiol. 2000; 86(1): 17-23. Carlson JJ, Norman GJ, Feltz DL, Franklin BA, Johnson JA, Locke SK. Self-efficacy, psychosocial factors, and exercise behavior in traditional versus modified cardiac rehabilitation. J Cardiopulm Rehabil. 2001; 21(6): 363-373. Focht BC, Brawley LR, Rejeski WJ, Ambrosius WT. 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