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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 Jul 31, 2010

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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 [2]  COPD: reduces risk of exacerbations, improves ventilation & strengthens respiratory muscles [3]  Osteo- and Rheumatoid arthritis: maintain full joint excursion [4] 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  Conditions • Type II Diabetes • Hypertension • Chronic Obstructive Pulmonary Disorder • Emphysema • Coronary Disease • Cardiovascular Disease • Rheumatoid Arthritis • Osteoarthritis  Adherence • Adherence • Compliance • Motivation • Guideline Adherence  Exercise • Exercise • Physical Activity • Walking Database Search  PsychINFO  Cochrane Database of Systematic Reviews  Web of Science  Google Scholar  MEDLINE  CINAHL  EMBASE  PEDro  Sport Discus  PubMed Period of time searched: 1950 – November 29, 2009 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 • 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 Facilitation (13 articles) 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 • • 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 significant Facilitation   Counselling [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 measures Facilitation •Group Mediated Cognitive Behavioural Focus [23-26] 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  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  The Arthritis Society. Exercise and Mobility: Use It or Lose It [Internet]. 2008 [updated 2008 Feb 23; cited 2010 Jul 21]. Available from:  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:  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 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): 59-62 References 1. 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. 2. 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. 3. 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. 4. 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. 5. 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. 6. 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. 7. 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. 8. 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. 9. 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. 10. 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): 414-423 11. Clark 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. 12. 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. 13. 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. 14. 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. 15. 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. 16. 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.


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