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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

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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 Informationœ CVD is the primary cause of death in Canada [1]œ By 2030 COPD will be 3rd leading cause of death world wide [1]œ 9.3% US population suffers from diabetes mellitus, of which 90% have Type II Diabetes [2]Benefits of Physical Activityœ Type II DM: regulates glucose levels [2]œ COPD: reduces risk of exacerbations, improves ventilation & strengthens respiratory muscles [3]œ Osteo- and Rheumatoid arthritis: maintain full joint excursion [4]Poor Adherenceœ Poor adherence is associated with a reduction in treatment effectiveness leading to poorer health [5]œ ~30-60% patients fail to adhere [6]œ The cost of treating non-adherent patients exceeds that afforded to the treatment of adherent patients [5]Rationaleœ Many studies have investigated barriers to exercise adherence or predictors of patient adherenceœ Limited 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 Strategyœ Conditions• Type II Diabetes• Hypertension• Chronic Obstructive Pulmonary Disorder• Emphysema• Coronary Disease• Cardiovascular Disease• Rheumatoid Arthritis• Osteoarthritisœ Adherence• Adherence• Compliance• Motivation• Guideline Adherenceœ Exercise• Exercise• Physical Activity• WalkingDatabase Searchœ PsychINFOœ Cochrane Database of  Systematic Reviewsœ Web of Scienceœ Google Scholarœ MEDLINEœ CINAHLœ EMBASEœ PEDroœ Sport Discusœ PubMedPeriod of time searched:1950 – November 29, 2009Study SelectionInclusion 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 measureStudy SelectionExclusion Criteria• Not published in English• Animal studies• Case Study• Underlying pathology that would restrict ability to adhere to or participate in a physical activity programQuality Assessmentœ PEDro Scale (11 categories)• Low quality < or equal to 3 • Moderate quality = 4 or 5 • High Quality > or equal to 6  œ Oxford Center for Evidence-based Medicine Levels of Evidence• Rated as either 1b or 2bœ On Average, the quality of articles are rated as HIGH• Mean score of 6/11The picture can't be displayed.ResultsSelf Mediated Approachesœ Accountability• Diaryœ Empowerment• MediaSelf Mediated Approachesœ Accountability – (2 articles) [7-8]• Statistically significant increases in adherence with use of diary to record physical activityœ 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 groupsPractitioner Mediated Approachesœ Intent• Contractsœ Facilitation• Counselling• Telephone• Face-to-Face• GMCBœ Action• Exercise groupPractitioner Mediated Approachesœ Intent (1 article) [12]• 15 of 63 would not sign contract• Signed vs. not signed: 65% vs 20% adherence rateœ 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 programPractitioner Mediated Approaches• 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 groupsœFacilitation (13 articles)Multi-Faceted Approachesœ All included counselling in combination with an additional intervention•Media•Diary• PedometerMulti-Faceted Approachesœ 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 adherenceœ Diary (2 articles) [28-29]• 3 vs 4 month intervention• Articles found a statistically significant or a trend towards positive change in adherenceœ 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 adherenceResultsœ 27 articles based on 26 trialsœ 26 demonstrated positive adherence changes with an adherence intervention toolœ 14 studies showed statistically significantincreases in adherence œ 1 study showed a non-statistically significant decreased adherence trendDiscussionIndividual Mediated Strategiesœ Accountability•Diaries [7-8]• Offer accountability• Self• Practitioner• Produced good short-term and long-term effectsIndividual Mediated Strategiesœ Empowerment•Media [9-11]• Information empowers good decision making• No one form appeared superior • Timing of delivery had no notable effect• No long-term dataPractitioner Mediated Strategiesœ Intent• Contracts [12]• Trend toward increased adherence• Low standard for adherence• Results may present biasPractitioner Mediated Strategies•• Short-Term • Showed stronger evidence for increases• Long-Term• Demonstrated increases, reduced from short-term• Follow up study reinforced this trend• 6 months• Point at which trials split from statistically significant to non-statistically significantœFacilitationCounselling [2, 15-22]Practitioner Mediated Strategies• All showed trends toward increased adherence• Short-Term• Increases not as strong compared to long-term• Long-Term• Strong evidence for increasing adherence• All self report measuresœFacilitation•Group Mediated Cognitive Behavioural Focus [23-26]Practitioner Mediated Strategiesœ Action• Group Exercise Class [13-14]• High drop-out rates• Trend toward increased adherenceMulti Faceted Approaches œ Counselling PLUS [27-32]• Media• Diary• Pedometerœ All combinations helped to increase adherenceœ No one combination is superior to the nextœ Combining strategies is more effective than a single strategyLimitations of Researchœ Poor comparability between studiesœ No standard definition or measurement for adherenceœ No standard for outcome measures• Many self-reportœ Poor generalizability of resultsœ Sparse long-term follow up dataConclusionImplications for Practiceœ Adherence intervention tools have a positive effect on client adherence œ Any strategy is more effective than noneœ Make adherence a focus of patient programsœ Consider patient preferenceœ Type of tool appears to be of little importance• Consider client preferenceImplications for Researchœ Adherence definition & measure is not consistentœ More research is needed:• Larger sample sizes• Multi-site trials• Between group analyses• Intervention tools• Disease populations• Expand intervention tools repertoire• Long-term follow upInvestigator’s Recommendationsœ INSERT FORMATTED TABLEAcknowledgments œ Special Thanks Our Supervisor Linda Liœ Also:• Darlene Reid• Elizabeth Dean• Charlotte Beck• Dean GuistiniQuestionsReferencesœ World Health Organization. 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